Laserfiche WebLink
---------------- <br /> APPLICATION <br /> --------------APPLICATION FOR PERI[I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENV I RONI[F1ITTAL HEALTH DIVISION ivo CIO41A1t <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 er <br /> PERMIT ESPY RES I YEAR R M DATE S <br /> (Complete in Triplicate) <br /> Application is hereby made to Baa 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 Health Services. <br /> + I <br /> Job Address �r City r 011 Lot Size/Acreage <br /> Jr 1 <br /> V Owner's Name k1 LJ�'11'1, Address 11� 6 l �&� �'�i��,1 _ Phone <br /> VContractor ®/1�n�.Y' Address 9, sem, !' License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL R PLACEMENT it DESTRUCTION 0 Out of Service Well ❑ � <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Fl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Q` <br /> I'I Public rl Other F1 Delta Depth of Grout Seal Type of Grout j <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Soul Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done I <br /> Well Destruction ❑ Well Diameter Sealing Material A Depth 1 <br /> + <br /> Depth Piller Naterial i Depth [� <br /> SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I TRUCTION No ptic system eqPTWt6dif public sewer is <br /> ilable wit feet.) <br /> Installation will serve: ' nce Commercial_ Other <br /> Number of living units: rot bedrooms <br /> Character of&ON to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Foun n Property Line <br /> LEACHING UNE ❑ No. lnes Tota th/size <br /> FILTER BED t: <br /> Well Foundation Props e <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DiS AL 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 itignalure 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 Califomla." <br /> The applicant4st call for all r wired insPections. Complete drawing on reverse side. <br /> v/Si9n� Title: W iq Date: -_3 <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: /o Q6e�cL <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 i <br /> INFO FEE AMOUNT DUE AMOUNTnR�ErMITTED CK RECEIVED BY DA�/J /PyER�MjIT'NO. / <br /> . EH 14-26 <br /> 4-2;i EV:r/Rill <br /> tbw - ✓ yam.[ / <br /> EH 2a <br /> i <br />