Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SE1,14ICES j �,�•��;�-•� <br /> ENVIRONMENTAL HEALTH DIVISION � ' 1��)VI <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> njioo - <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> -PERMIT EXPIRES i YEAR FROM DAIF ISSUED <br /> (Complete in Triplicate) t�I�/ <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the v0 VIEW c I LT This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Ruleep�� n'Cof San <br /> Joaquin County Public Health Services. <br /> Job Address 1 790 F.- T.a#h�Lwa City Lathrop Lot Size/Acreage 1(} ac <br /> Owner's Name Pat and Cheryl Mitchell Address P.O. Box 1219 Lathrop _ _ Phone858-25291 <br /> Contractor Osterberg & Stewartgddress 2523 River Rd. ModestRicense No. 446670 Phone 209 537-576 <br /> TYPE OF WELL/PUMP: NEW WELLX WELL REPLACEMENT CJ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION 7 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1. <br /> MDISPOSAL FLD.� ( <br /> _ PROP. LINE <br /> '' W GS <br /> FOUNDATION WELL/2219L WELL� OTHER WELL PITS/SUMPSN 3 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation�/D Dia. of Well Casing <br /> X Domestic Private Gravel Pack Ll Tracy Type of Casing_ a✓C Specifications <br /> I'l Public f-1 Other n Delta Depth of Grout Seal _7 Type of Grout1�F-r�T <br /> I I Irrigation c9_'�'.Appfox. Depth I I Eastern Surface Seal Installed by AT-12;4W r4(t ' 4-S-,RZuW4K7_ <br /> Repair Work Done LJ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth \ <br /> Depth Filler Material 8 Depth Q , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION f I DESTRUCTION I I (No septic system permitted if ptiblic 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 soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity — .f No. Compartments <br /> PKG. TREATMENT PLT. D Method of Disposal <br /> Distance to nearest: Wet[ Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of tines Total length/size <br /> FILTER BED C1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 subcontracting 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 applicant m for a i r r d i ions. Complete drawing oneverse side. <br /> Signed Title: Date: <br /> FORD RTM T SE ONLY C <br /> Application Accepted by c C Date Area <br /> Pit or Grout Inspection by Date ~�r v Final Inspection by Date 3��U <br /> Additional Comments: / <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 <br /> INFO <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'N0. <br /> . EH 13-24(REV.rites! I -2 <br /> a / s' �`G�` 7}���Q <br /> EH t�.2y (o jam' TV C/ V <br />