Laserfiche WebLink
F <br /> f <br /> APPLICATION FOR PERMIT <br />� SAN JOA UIN CO <br /> Q COUNTY PUBLIC HEALTH SERVICES <br />[ ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON- AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 r <br /> PERMIT EXPIRES 1 YEAR FR -M- DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install_ the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> T Job Address l 1 _IV 0 //-- AC_4� r Lot Size/Acreage <br /> S w� <br /> Owner's Name Address E �— C)�6.3 <br /> /� �f Phone f <br /> Contractor_. �! C'l Address • J Z? 773p - (�t/�,ZS sl <br /> License No. Phone /� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION * SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK -1y SEWER LINES DISPOSAL FLD,L_ PROP, LINE 1-0 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, <br /> n Industrial �,ry ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f' 4j <br /> )kzomestic/Private Gravel Pack L) Trac 1 ,�ia. of Well Casin,gCCc.�tn (, <br /> f'1 Public y Type of Casing ► �� l Specifications .L..., U� <br /> !:1 Other ❑ Delta Depth of Grout Seal �v k ti^Type of Grout -/1LLi <br /> I I Irrigation .Approx. Depth l I Eastern Surface Segal Installed byJ �� L,. <br /> Repair Work Done 0 Type of Pump H.P. +I <br /> State-Work Oona';• ID&-A cr, <br /> 'Well Destruction Wel! Diameter Sealing Material 4 Depth <br /> DepthFiller Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION'I ! DESTRUCTION I I (No septic system permitted if public sewer is <br /> Installation will serve: Residence Commercial I i available within 200 feet,► <br /> Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: r <br /> SEPTIC TANK. Water table depth <br /> ❑ Type/Mfg �r! Ca acit �'��k6. TREATMENT TREATMENT PLT, Cl P Y No, Compartments <br /> x s ` Method of Disposal " <br /> Distance to nearest; <br /> Well Foundaiion + <br /> Property Line, <br /> LEACHING LINE �L�tNo&neL gtfi 4f lines "µ"'"` "- <br /> FILTER BEDTotal length/size <br /> ❑ Distance to nearest. Welt Foundation <br /> Property Line <br /> SEEPAGE PITS I I Depth Size _' 4E <br /> SUMPS Number <br /> LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordi <br /> rules and regulations of the San Joaquin County nances, state laws, and <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the s V <br /> employ any person in such manner as to become subject to workman's compensation lawsofCalifornia," Contractor's or sub-contracting not <br /> permit is signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call f!P all r quired ins ti ns. Complete drawing on reverse side. <br /> Signed X q <br /> Title: Z LAj MOW Date: ��4" /Z• <br />.: FOA DEPARTMENT USE ONLY <br /> Application Accepted by Area 9, <br /> Date <br /> Pit or Grout Inspection f <br /> Date ^21 Final lnspectio� by <br /> ,Additional Comments; P � �� d 1"i i= f r <br /> Applicant - Return all copies to. San Joaquin County Public Health <br /> Services, Environmental Health Permit/services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 °r <br /> FEE AMOUNT DUE AMOUNT REMITTED CK Ai <br /> NFO <br /> �y CASH RECEIVED By DATE PERMIT'NO. j <br /> 124(REV.1/R5) U D V O 0 r h <br /> �� !oo.e., "A-,_ E-RII <br />