Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 AID billa0w , <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 YEAR PROM DATE ISSUED N`4 <br /> (Complete in Triplicate) <br /> Application is hereby made to Stw Joaquin County for a permit to conetruct and/or install the work herein desc abed. This <br /> application Is made in compliance,'With San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. fl <br /> FJob Address _ ��z ��S H 1 '� _b%_ City GC Lot Size/Acreage <br /> /t� <br /> Owner's Name _7ke_s' L Or.? Z 1 Pr Address �z© So' �'`ti t� r 0 S Phone <br /> • C nIfactof S l Address License No. Phone <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Nell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA �� PROP. LINE <br /> FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA__ZOVORUCTION SPECIFICATIONS <br /> 0 Industrial O Open Bottom ❑ Man Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications <br /> 13 Public is Other # ❑ Delta Depth of Grout Seal Type of Grout <br /> M Irrigation ._ . <br /> Approx.' <br /> Depth d Eastern Surface Seal Installed by <br /> ' Repair Work Do Type of Pump: H.P. State Work Done_ <br /> Walt Dastru fon O We)I Diemeter:j Sealing Material i Depth <br /> Depth ! Filler Material is Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION L`I REPAIRIADDITION M DESTRUCTION INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of $oil to a depth of 3 feet: Water table depth \1 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, Cl I Method of Disposal <br /> Distance to!nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Tota) length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line r <br /> i <br /> SEEPAGE PETS 11 Depth Size Number <br /> SUMPS LI Distance to'iJnearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin"County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> .he applicant mut call for all required inspections, Complete drawing on reverse side. n <br /> �igned Title: t-tr7�Pim �'" l 2 7+� <br /> Data: <br /> TMENT USE ONLY <br /> Application Accepted by Data, �� �—`� Area <br /> Pit or Grout inspection by ! Date Final Inspection by Date a� <br /> 1b <br /> Additional Comments. _ <br /> i <br /> Applicant Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> =ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> r <br /> 9H 13-24 1AEV.r/n SlCIO <br />