Laserfiche WebLink
APPLICATION FOR PERMIT , <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXP I RES .l 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 <br /> +�}Public <br /> C�Health Services. <br /> ' <br /> Job Address L n '+— C` ►��';J ` City t Size/Acreage <br /> Owner's Name Address `' t Phone 33 1- 3 <br /> T]J �70� S YTs�j�y q 9 2 <br /> tractor Address License No. Phone a <br /> ,TYPE OF WELL/PUMP: NEW WELL ❑ { WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION '❑ SY TEM REPAIR 0 OTHER ❑ Monitoring Well ❑ } <br /> DISTANCE TO NEAREST. SEPTIC TANK It SEWER LINES DISPOSAL FLD. PROP. LINE <br /> /FOUNDATION AGRICULTURE E OTHER WELL PITS/SUMPS .r <br /> INTENDED USE TYPE:OF WELL:' PROBLAAREACTRUCTiON SPECIFICATIONS0 i dustrial C3 Open Bottom ❑ ManWed Excavation Dia. of Wall Casing. Domestic/Arivate ❑ Gravel f ack 17 TracfCasing Specifications <br /> 1'I ublic 1-1 Other n DeltoI Grout Seal Type of GroutI I trrigation —Approx. Depth l I Easts Saul Installed by t <br /> RepFir Work Done U Type of Pump H.P. Stats Work Done_ ' <br /> Wag Destruction C1Well Diameter " Beating Material A Depth 4 <br /> Depth Filler Material A Depth + <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I —REPAIWADDITiON I I—DESTRUCTION I I INo septic system permitted if public sower is <br /> R available within 200 feet.) <br /> Installation will serve: Residence Commercial ther <br /> 1.,.,�- _.._ - 4 <br /> Nfumber of living units: Number of bedrooms 3 <br /> i Character of sod to a depth of 3 feet: b e <br /> 0 _ w"a;ter cable depth - k <br /> SEPTIC TANK 0 Type/Mfg Capacity V Na:-Compinmerits i <br /> PKG. TREATMENT PLT. ❑ <br /> ' Menne DitIposai. <br /> Distance to nearest: Well _ U Foundation *�" Prgpeny Line"_ U If I � A- <br /> LEACHING LINE ❑ No. 3 Length of lines - - - -To al length/size <br /> I F1.ILTER BED O 'Distance to nearest: %Well oundation. Properly Line 3 ` <br /> SEEPAGE PITS 1 1 Depth i Size umber d <br /> f <br /> SUMPS It Distance to nes it: Well'-Z- Property line 17 <br /> 1 <br /> DISPOSAL PONDS ❑ t .•+" �� <br /> 1._ R <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 /> rubs and regulations of the San Joaquin County <br /> Norrie owner or licensed agent's signature candies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> 'sloy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> canifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subisct'to workman's compensa• t <br /> tion� we of California." ; <br /> The sppficartt mu call for ail r red inspec ions. Complete drawing on reverse side. <br /> Signed X r Title: <br /> I -DEPARTMENT USE ONLY f <br /> Application Accepted by Date s, J Area_ Z 's &) ,e <br /> Grout Inspection by Date 3 Final Inspection by I Date <br /> Add tional Comments: r <br /> Applicant - Return all copies to: San Joaquin County Public Health Services e <br /> Environmental Health Permit/Services <br /> y. 445.N San Joaquin, P O Box 2009, Stkn, CA 95201CK ff <br /> FEE - <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 9Y DATE PERMIT"N0. <br /> S. EH 1}24 IREV.i r <br /> EH 14.26 �� '� �t �..t <br />