Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HE <br /> ALTH ENVIRONMENTAL HEALTH DIVISIONSERVICES <br /> P O BOX 2009, MmTON, CA 95201 <br /> (209) 468-3447 , <br />- 5 ' <br /> .11Z1111 T Ex <br /> Y <br /> ` (Complete ill Tripiicate) <br /> Application is hereby made to San Joe <br /> 4uiCounty for a permit <br /> appllcation-ia lti <br /> made in cance to construct and/or install the work herein described. <br /> r Joaquin County Public HealthThis <br /> gervicesh San Joaquin County Ordinance No. 5kg and 1862 and the Rules and Regulations of ThTh <br /> Job Address S 4 n, r <br /> _ City`ar <br /> Owner's Name Lot Size/Acreage 7-0 <br /> U G <br /> r Address SAIW�� Phone 33 kl I <br /> Contraclor f- p 1 <br /> �f Address <br /> TYPE OF WELLlPUMP: <br /> NEW WELL 'License N3273�r�--Phon -7'e3J <br /> WELL REPLACEMENT Cl "` " i T/Z <br /> PUMP INSTALLATION,i f _ DESTRUCTION ❑ Out of Service well Cl <br /> DISTANCE TO NEAREST:'SEPTIC TANK SYSTEM REPAIR.C1 -' ­--,�OTHFR"p <br /> --- - .�� SEWER LINES ate' Monitoring well L? <br /> FOUNDATION -- DISPOSAL FLD,�_ PROP. LINE 'LoaQ� gR W <br /> _ AGRICULTURE WEL1� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA -�-�- PITS/SUMPS .� <br /> 0 Industrial U Open Bottom �""�-- CONSTRUCTION SPECIFICATIONS <br /> i�Domestic/private ❑ Manteca Dis, of Well'Excavation <br /> Gravel Pack 0 TracType-ofDia. of Well Casing <br /> " <br /> ❑ public y Casing• !/� g <br /> I-1 Other ❑ Delta y y Specifications-'"`F` f <br /> Cl Irrigation >� A Depth of Grout Seat ,� - ,�. <br /> pproK. Depth ❑ Eastern --- TYpe'of,Grout <br /> Repair Work Done U Type of pump eL Sv Surface Seul`Instailed by7 F L <br /> Well Destruction ' H P' Scare Work Done dJ✓ .F <br /> "_C) -Well Diameter _ Sealing Material i Depth <br /> Depth Filler Material & Depth " <br /> ' TYPE OF SEPTIC WORK; NEW"INSTALLATION jLJ REPAIRlApDt7fON 1=f pESTRUCTtON Ci {.No se'pric•system permitted <br /> KInsteHation inrifiierve:'Reiidenco if public"tewer is <br /> '� available within 2t�faet,lr <br /> ""�'�Cv►nrherciat '� ther-:�.-t ,...` - <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3-fest: r� , <br /> SEPTIC TANK. Q Type/Mfg Water table depth l <br /> f <br /> PKG. TREATMENT PLT, Cl Capacity No. Compart <br /> ments t <br /> ~'' 'F Method of Disposal 9 �� <br /> Y Distance to nearest: Well Foundation <br /> --� " Property Line _ <br /> LEACHING UNE. 0 No. & Length of lines [� <br /> FILTER BEDTotal length/size I- a <br /> f-1 Distance to nearest: Well _._" Foundation <br /> Property Line f <br /> SEEPAGE PITS , i I Depth .. <br /> Size Number � <br /> 'SUMPS LI Distance to nearest: Well <br /> DISPOSAL PONDS Foundation Property Lina <br /> ❑ f <br /> I hereby'certify that I have prepared this application and that the work will be done in accordance with San Joaquin county Ordinancate laws n a <br /> rules and regulations of the San Joaquin county and <br /> Home owner-or licensed agent's signature certifies the foliowin ! certify that in the .T <br /> employ an 9 performance of the work for which this permit is issued, I shall not <br /> p Y e person in such manner as to become subject to workr»ari's�oinpensation-Iawb.of-California,'Contractor-s•hifing or sub-corftracling signatu <br /> certifies the following: '9 certify that in the performance of the work for which this permit is issued, f shall employ lion laws Of California." p y persons sub;j"t to worlgrf`e compensa- <br /> The applicant must for all re wired inspections. Complete drawing on reverse side., <br /> Signed <br /> Title:- ; , Date: eo <br /> ..� li <br /> CDEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit ort Inspection by <br /> Final Inspe-ction by <br /> Additional Comments: Date i -« .r <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ' y ENVIRONIdENTAL HEALTH DIVISION PERNIT/SERVICES <br /> 446 N SAN JOAQUIN, P 0 BOX 2009, STUCKTON, CA 85201 <br /> } I <br /> Ft E AMOUNT DUE AMOUNT REMITTED LK.INFO , REC&VeD BY DATE PERMITNO.N13-211REV.tih4i a <br /> hp <br />