Laserfiche WebLink
t � <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 SP <br /> PERMIT MWIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application to hereby Bade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is Bade in catff�liance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 10 dclv� <br /> Job Addreq Y J City J Lot Size/Acreage <br /> 15 � _YL <br /> Owner's NormAdd�rtess �c„ l�Phone - <br /> Contractor Address / V J Y LicensE'No. ra/ w Phone Z <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well O <br /> PUMP INSTALLATION '0 SYSTEM EPAIR L OTHER O Monitoring Well C3DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHEJ WELL . PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C CTION SPECIFICATIONS ' w1 <br /> E1 Industrial .0 Open bottom ❑ Maniacs Dia. of ell Excavation Dia. of Well Casing Vn" <br /> f7 Dontastic/Prfwte O Gravel Pack ❑ Tracy, Type. CasinpSpecifications V+ <br /> 1'1 Public C1 Other n Dept of Grout Seal Type of Grout t) <br /> 1 (Irrigation _Approx. Depth Eastern Su ce Soul IAstalled by / ` <br /> Ripely Work Oona U Type of Pump H.P. State Work Dons _ V 1 <br /> Well Destruction O Well Diameter eealirtt Materiil &!Depth � <br /> Depth i liller'Material Ddpth ,_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I i�EPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is i <br /> await bl wi in 200 feet.) <br /> Installation will serve: Residence� Commercial�_ Other j <br /> Numbw of living units: Number of bedrooms - -- ' -- <br /> Character of IoM to a depth of 3 feet: t Water table ilspth <br /> SEPTIC TANK. ❑ Type/Mfg C Ii 11 <br /> �! No. Compaknilents <br /> PKG. TREATMENT PLT. ❑' c� �' Method of Di <br /> ell Fond <br /> tfposal,'. <br /> Distance to not restT_ Wuation Property Line 01 <br /> LEACHING LINE O No. b Length of lines t I Oyu al length/size <br /> FILTER BED O Distance to nearest: WNI oundation Property line <br /> I <br /> SEEPAGE PITS 11 Depth alois $f:e mbar ' <br /> t{ <br /> SUMPS LI j Distance to net t:' Wall Foundation Property L" i! <br /> DISPOSAL PONDS O tt <br /> I hereby certify that 1 have p spared this application old that the work will be done in accordance with Sin Joaquin County ordina ces, state laws, and <br /> rubs and regulatkwA of the tan Joaquin County <br /> Home owner or licensed Agarlt's signature certifies the�oflowing: "I certify that in the performance of the wdrk fbf MiEfi this Otfft is issued, I shall riot <br /> employ any parson in such n4hn&is to become subjs t to workman's compensation laws of California." Contractor'$hiring or sub-contracting signature <br /> ceftMU the following: "I Certify that in the performance of the work for which this permit Is issued, I shall employ petsons subject to woiltman's componss- <br /> tioh saves of CMlfomia." r <br /> ThIs applicant mus all for all requir nspocYons. Complete drawing on reverse side. / <br /> SiOned Title: Date: 3^) <br /> f <br /> 0 MENT USE ONLY <br /> Apphcstfon Accepted by l Date 1 Area a Z1 <br /> Pit or Grout Inspection by Date-:-- Final Inspection by Date Z ,t j <br /> Additlonal Comments: <br /> Applicant - Return all copies to: San Joaquin County public Health Services i <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 (� <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED !Y D TE PERMIT NO. <br /> 1/x151 <br /> x ;.3- <br />