Laserfiche WebLink
5 <br /> APPLICATION FOR PERMIT <br /> ! SAN JOAQUIN COUNTY PUBLIC HEALTHSERVIC S <br /> ENVIROMMTAL HEALTH DIVISION >< <br /> 445 N SAN JOAQUIN, PHONE (209)468-342 <br /> P O BOX 2009. TON, CA9520 <br /> STOCK ANNFD-:`,`:. <br /> 1 <br /> i ERMIT E%PIRRS 1 VVAD FROM--DATE ISS <br /> UEp <br /> (Complete in Triplicate) <br /> Application is hereby nrttde to San Joaquin Count for a <br /> application is made In corgpl3ance with San J y permit to construct and/or install the work herein described. This <br /> Joaquin County Publle'Health Services, Joaquin County Ordinance No. 549 and 1$62 and the Rules and R_egulatione of San <br /> Job Address 31/ <br /> City ��^ Lot Size/Acreage <br /> Owner's Name Sd t7 4#7' &�L& Address �•C) r V.4,aJ�/ <br /> Phone <br /> l:0nhAddress actor �1 �f I�' L o a / fc _ G <br /> E_icense No. �d�s�S phone 33���/ <br /> TYPE OF WELL/PUMP: <br /> NEW WELL El WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD, PROP. LINE <br /> ;FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE 1, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial - ❑ Open Bottom ❑ Manteca T Dia. of Well Excavation <br /> Cl Domestic/Private ❑ Gravel PackDia. of Well Casing <br /> ('I <br /> Publrc <br /> ❑ Tracy Type of Casing_ Specifications _ <br /> 11 Other Cl Delta Depth of Grout Seal <br /> Type of Grout <br /> l I Irrigarion __.Approx. Depth I I Eastern Surface Seat Installed by <br /> Repair Work Done ❑ 'type of Pump N.P. <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth State Work Done_ <br /> • Depth filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION <br /> p {Nq septic system permitted if public sewer is ,� <br /> vailable within 200 feet.) {� <br /> Ins n will serve: Residents .Commercial_ Other S <br /> Number of liver its; Number of bedrooms <br /> a Character or sod.to a 3.feel: <br /> — SEPTIC TANK. Type/ ater table depth <br /> ❑ W"— ...,:, <br /> PKG. TREATMENT PLT. 1' CapacityCompartments. <br /> Method of Di <br /> Distance to nearest: _Well is �I' r <br /> undation .Property Lina <br /> —UEACHING LIME+ ❑ 'i <br /> No. 8 Length of lines Tot h/size <br /> FILTER.BED ❑ Distance to st :. Well "I` i <br /> � i Foundation Property i <br /> SEEPAGE-PITS <br /> I pth { Size °C Number . <br /> SUMPS . <br /> LI j,Distance to nearest: Well Foundation <br /> DISPOSA DS ❑ ---�-- Property Lina <br /> i <br /> 1 certify that I have prepared this application and that the work will be done in accordance with San-Joaquin:county ordinances, stele laws, and <br /> rules-and regulations of the San Joaquin County <br /> .Home owner or licensed agent's signature certifies the following: "`" _.- `- <br /> employ an 6: "1 certify that the pe>= ;nanco oPthe-work for which-this-permit is issued;I shall not <br /> y person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> tion <br /> nth frq�jf "1 carti that in the performance of the work for which this permit is issued, I shall employ Persons subject to workman's compsnsa" <br /> The applics t st II for } d. <br /> inspactiona. Complete drawing on rev <br /> arse side. <br /> XSignmad Title: a Ile Date: 3-7� 1 <br /> �l <br /> Application <br /> ENT USE ONLY <br /> Accepted 6yA � .Date ( Area <br /> Pit or Grout In ` <br /> ttpection by Date Final Inspection b <br /> oat s� � r <br /> Additional Commants: - <br /> Applicant - Return all copies to: San Joaquin County Publi alth Services <br /> II Environmental Health Permit/Services <br /> 445 N San Joaquin, p 0.73wt-2009, Stkn, QA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K `" - <br /> INFO EIVED ByD)(TE' PERMIT'NO. <br /> Za <br /> 3 <br /> % <br />