Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOA 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> (Complete in Triplicate) <br /> Application is hereby rade to San Joaquin County for a permit to construct and/or install the work hertiln 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 /> Job Address City AfA Lot Size/Acreage ,u ± <br /> Owner's Name K__.,IA knlf!�r- Address f• eq q 77'c <br /> - - — Phone <br /> Conlraclar t h Address -tl`i[�� � ct fY_ License No. 3 $ 3 Phone Co`%-a �7 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> SYSTEM REPAIR 0 OTHER 0 Monitoring Well <br /> PUMP INSTALLATiONX C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK +�Q r SEWER LINES DISPOSAL FLD. PROP. LINE r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS SO j <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> domestic/Privaie 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public 1.1 Other D Delta Depth of Grout Seal Type l!of Grou?ZZX �c-5 <br /> Cl Irrigation 3OJ Approx. Depth 0 Eastern Surface Seal Installed by Il Gt / 6-- <br /> Repair <br /> YyRepair Work Done 0 Type of Pump S H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth i <br /> Depth Filler Material i Depth i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION 0 DESTRUCTION 0 (No septic system permitted if public sewer is <br /> • .." available within_200 leet.l, _i � <br /> Installation will serve: Residence Commercial____, Other f <br /> Number of living units: Number of bedrooms I <br /> i <br /> Character of *oil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity ..No. Compartments <br /> PKG. TREATMENT.PLT. Cl �- Method of Disposal <br /> Distance to nearest: Well Foundation-. Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line ! <br /> SEEPAGE PITS 11 Depth Size Number I <br /> SUMPS LI Distance to nearest: Well foundation Property Line <br /> DISPOSAL PONDS 0 } <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 /> -Home-owner-or-licensed-agent's-signature-conif ies-the-followi ng:-1 comity that-in-the performance-of ihe-work-for-which this-permit is issued, I shall not <br /> employ any person in such manner its 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 compenaa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side, <br /> Signe Title: -:5 <br /> Date: blllql <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date CE A L'q L 1 Area <br /> Pit or Cut Inspection by Date ` Final Inspection by/ Dote / <br /> v f <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 1 <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> !�NFO <br /> AMOUNT DUEAMOUNT-REMITTED CASH CK RECV 11) BY- DATE PERMIT NO. <br /> EH 13.24 1AEV.r i n 6l vEN <br />