Laserfiche WebLink
r <br /> APPLICATION FOR PERMIT N <br /> k <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> I P O BOX 2009, STOCKTON, CA 95201 <br /> I <br /> > <br /> PEWIT EXPIRES 1 YEAR FROM 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. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin�County Public Healt rvices. <br /> 93-'f_0 ' City Lot Size/Acreage <br /> Job Address ,' <br /> Owner's Name 2 <br /> " �` Address Phone <br /> Contractor <br /> Address V icense Nof_21_0�IU Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out t4 Service Well G� <br /> OTHER ❑ ldonitoring Well ❑ r„h <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST:-SEPTIC..TANK-; SEWER-LINES —_ �' �" 'DISPOSAL FkD. .4_ PROP. LINE k <br /> F, FOUNDATIONS AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ► 3 <br /> CDia. of Well Casing Industrial ❑ Ogen Bottom ❑ Manteca Dia. of Well Excavation.� g <br /> T.1 Domestic/Private ❑ Gravel Pack7i ❑ Tracy Type of Casing_ Specifications r. <br /> 1 i a p. <br /> i'1 Public I-1 Other Cl Datta Depth of Grout Seal Typs'of'Gro uI <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal installed by k.. <br /> Repair Work Done U Type of Pump'' T H.P. tato Work Done <br /> , t 1 <br /> Well Destruction ❑ Well Diameter t Sealing Material i Depth � ..., <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WOf1K:._.NEW INSTALLATION l4r REPAIR/ADDITION I ! ,DESTRUCTION I I JNo septic system permitted it public sewer is <br /> r f available within 200 feet.1 d <br /> Installation will serve: Residence commercial_ Other <br /> k Number of living units: Number of bedrooms t <br /> Character of;soli to a depth of 3 feet: Water table depth <br /> t <br /> E SEPTIC TANK� ,�:# ❑ Typs/Mfg_ =• _98_ptcity4ivo No. Compartments \4 y <br /> PKG. TREATMENT PLT. ❑ Method of_Djapo�I <br /> Distance to�nearest: Well ope <br /> ��.�b - Prn <br /> --. Total ten th/size <br /> LEACHINGf LINE s ❑ No. a Length of lines- _ g <br /> FILTER BED i` ❑ Did encs lo`rtearest: Weis r o Foundation Property Lina <br /> SEEPAGE PITS f I h T13apth e� Size ® umber <br /> t <br /> SUMP L b Distance to nearest: Well 1 Foundation Property Line <br /> ISPOSAL PONDS­ ❑ <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 /> Horns 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 /> The applican roust cell for uired ins ct s.`Complete drawing on reverse side. n <br /> SignedX lfl�n Title: Date:D-44 (� <br /> " F LY <br /> IV 1� <br /> L Application Accepted by Dats Area <br /> /)or Grout Inspection by �- ate Final Ins tion by Data3 <br /> Additional Com" f9272 <br /> Applicant - Return all copies to: San Joaquin County Public Health Services Q ✓ e'er-rr��s <br /> ' Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, 3tkn, CA 95201 el <br /> l <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED J CAS <br /> H RECEIVED BY DATE PERMIT'NO. <br /> .t�4 tb-24 IFIEV.1/N Srt d d -!�C)a V f 2 <br /> EM 14.7, <br /> S <br />