Laserfiche WebLink
f APPLICATION FOR PERMIT 1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 .I <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT MIRES IL YE FR M DATE SU <br /> (Complete in Triplicate) <br /> Application is hereby made <br /> •to Ban Joaquin County for a permit to construct and/or install the work herein described. This <br /> application in made in comliance vith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> / <br /> Joaquin County Public Health Services. /� <br /> Job Address d1 1 City Lot Size/Acreage 4Q A <br /> Owner's NameA--- <br /> AE& ��Address I I <br /> C Phone <br /> 1 Contractor ddress License fVa. Phone <br /> k , <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well-0 <br /> PUMP INSTALLATION 01 SYSTEM REPAIR p OTHER O MonitoringWell <br /> DISTANCE TO NEAREST: SEPTIC TANK ` `SEWER LINES DISPOSAL FLD. — PROP. LINE f <br /> F FOUNDATION AGRICULTURE WELL OTHER WELL--=~" PITS/SUMPS <br /> 9 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r n Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation �' Dia. of Well Casing <br /> VDamestic/Private Gravel Pack ❑ Tracy Type of Casing_ Specifications -_J I <br /> I.1 Public f-1 Other fl Delta Depth of Grout Seal dotType of Grout } <br /> I 1 Irrigation 2WApprox. Depth t 'I}I Eastern Surface Seal installed by <br /> Repair Work Dorm U Type of Pump Ft.P. Stats Work Done x <br /> Wall Destruction ❑ Wefl Diameter Sealing Material i Depth <br /> * Depth biller Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION I 1 INo septic system permitted if public sewer is f <br /> 1 ` � 'I ��� available_within_200.few.}._ <br /> 'installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of sob to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT-PLT"Ll_•'"•` <br /> Method of Disposal! <br /> [ Distance to nearest: Well _=Foundation Property Lina i <br /> iL <br /> # LEACHING LINE 0 No, & Length of linea Total length/size <br /> FILTER BED ❑ Distance to nealest:` .Well • --.Foundation Property Line <br /> \y r t _.. A h r <br /> SEEPAGE PITS I 1 Depth i Size Number <br /> SUMPS LI Distance to newest: Well c-- Foundation_F ! Property Lina <br /> DISPOSAL PONDS C1 „� t <br /> I hereby-cshify that I'have preparid this application and that the work will be done in accordance'with San Joaquin county ordinances, state laws, and <br /> rules and'rspuletions of the San Joaquin County _ <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance+5f the work for which this permit is.issued, I shall not Y <br /> employ arty person in such manner as to become-subject-to workmen's-compensation Iaws of California.” Contractor's hiring or sutkontracting signature <br /> certifies the following: "I certify that in the performance of the work.for which this permit is isiued, I shall employ persons subject to workman's com <br /> tion laws of Calif ar ia." A`i :. %--- _ .. I 1. pensa <br /> S" �,Ieledrawin.g <br /> The appliean must I r r uiradl' s rave 8'�Signed Ae Date:. <br /> O SE ONL - <br /> Application Accepted by All , <br /> 'Date_�. -. tlArea <br /> Pit or Grout Inspection by Date "'Z3' Final Inspection tLy Date <br /> Additional Comments: <br /> Apple _ <br /> icant°- tteturn al cops to: San Joaquin County Publi Health Services <br /> r ti <br /> * Environmental Health permit/Services <br /> t n 4— . 445 N San Joaquin, P O Box 2009, Stka, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMFTTEDif GASH RECEIVED BY DATE PERMFT'N0, L <br /> EH 13.74 FREV.tie 51 3 r (7� 1 ( O U , q3"_ I <br /> 41 EH 74.70 U �j <br /> y <br />