Laserfiche WebLink
APPLICATION FOR PERMIT .3 <br /> SAN JOAQUIN COUNTY PUBLIC $TALTH SE <br /> SNVIRONHHNTAL IWALTH DIVIS} IR <br /> 445 N SAN JOAQUIN, PHONE 2090 16Z <br /> P O BOX 2009, STOCKTON, CA5� <br /> R ✓ `�7l <br /> (Complete in Triplicate ! <br /> Application is hereby Stade to San Joaquin Couaty for a permit to construct and/or install the wort herein described. This <br /> spylicatioo is a-de in ccmliance with San Joaquin county Ordinance No. 549 and 1862 and the Rules and Reiulatlons of San <br /> Joaquin County PPu�bUc�Health Semites. <br /> Job Address '-`15 lt,%r Li`2 C-tL D1� /C� • Cily� j� <br /> Lot S1ulAcreve <br /> Owner's Name t Address e <br /> Conti ac � �' L.:Aderess 1` �1 { License No. Phor►s <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION O Out of Service Wil D <br /> PUMP INSTALLATION O SYSTEM REPAIR C1 OTHER O MoDltorins Well O <br /> DISTANCE TO NEAREST; SEPTIC TANK _ SEWER LINES DISPOSAL FL O. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTAUCT)ON SPECIFICATIONS <br /> Cl Industrial ❑Open Bottom O Manteca Dia. of Well Excavation_ Die. of WON Coming <br /> r I Dornestic/Private Cl Gravel Pack L) Tracy Type of Casing SW4f"tiOne <br /> I'I Public n Oltw fl Delta Depth of Grow Seal Type of Grout <br /> I Irtivation _Approx. Depth I I Eastern Surface Seat Insio5ed by <br /> Repair Work D&w Q Type of Purr, H.P. State Work Doan_ <br /> WON Destruction O WON Diarnater Sealing Material i :myth <br /> Depth lriilar Material y Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I !EPA19 AOOITIOI�FAC- DESTRUCTION I I INo septic system parmitled it public sewn is <br /> Y avarlabN wiltrin 200 lost.)*a serve: Residence— Commercial Other�_ � <br /> Number of living unite. Number Of be& 7 <br /> Chormctar of"to a depth Ol 3 feet: Zl� yI Water table depth i <br /> SEPTIC TANK O Type/Mfg , — Capacity No. Compartments <br /> PKG. TREATMENT PLT.D Method of Disposal <br /> Distance to nmaraat: Well. Foundation_ Property Line <br /> LEACHING LINE C1 No. 6 Length of lutes Taral length/sue <br /> FILTER BED 0 Distance to merest: Well Foundation _ Property Line <br /> /r <br /> SEEPAGE PITS XDepth Site w (lumber_ <br /> SUMPS LI Distance to nmarest: WON Foundation/C ProAirty Line S� <br /> DISPOSAL PONDS ❑ _ <br /> I hereby certify that I have Prepared this*Wication and that the work will be done in accordance with San Joaquin county adinantxs, stale laws, <br /> rules and tegulmliorn of the Son JOOrtuin County <br /> Home owner or licensed agsrn'm signmure oenifies the following: "I certify that in the porlomunce of the work for which this permit is iesumd, I shah not <br /> mrnploy any person in such mentor&a to become eubpwt to workman's compensation laws of California.'"Contractorb <br /> s hiring or sucontracting tignatwe <br /> cantFms the following:"I wnify that in the pmrformancm of the work lot which this permh is issued,I shall employ persoma subject to wotltmsn's cornpahss- <br /> tion Iowa of Califomis." <br /> The ApplimM can III 5 Od Intppctions. Complete drawing on reverse aide. y ` <br /> Sigined r ` Title: r Date: 1 <br /> FOR DEPARTMENT USE ONLY <br /> Appkatlon Accepted by Data —y-�,, At" <br /> or Grout Inwxmilon by Final Inspection byIf Jf, <br /> �_��/ �/ /•-���RC?✓�� <br /> Addhional Commonts: r 2 /�/r'C_ /2, �l.�i 1' /, /: at <br /> Applicant - aeturs all/coplce to: San Joaquin County Public Health Services <br /> 1 Sovironaentsl Health Permit/Servlcee <br /> `\ 445 N Ban Joaquia, P 0 Box 7009, 8tkn, CA 95201 <br /> fEEAMOUNT DUE AMOUNT REMITTED RECEIVED Y , PERMIT <br /> 1000 <br /> E late l l 4.ab i4ro <br />