Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES 1MYNIENT <br /> ENVIRONMENTAL HEALTH DIVISION RECEIVED <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009' STOCKTON, CA 95201 min2 � <br /> + .1: <br /> PEUIT EXPIRES 1 YEAR FROM DATE ISSID1�OIENTL ISA <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin Count for k herei S vI E$ <br /> pp q y permit to construct and/or install the work herei descr ed. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862�{nd the Rules and Regulations of San t <br /> Joaquin County Public Health Services. : <br /> Job Addresse City � � y Lot Size/Acreage <br /> G `t d 5� <br /> Owner's Name A dress Ca n�MS -L�4'­ Phone .2 <br /> Contractor SS?e Address +�� �'' ►�jt dck• License No. `'� Phon `1� <br /> —� <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ �Vellltgj 4 <br /> ,r <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES /On DISPOSAL FLD. N*- PROP. LINE0 � <br /> FOUNDATION /06 ! AGRICULTURE WELL OTHER WELL � PITS/SUMPS N� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> A Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation g77-- Dia. of Well Casing <br /> Cl Domestic/Private Gravel Pack ❑ TretlIa� ype of Casing_ f�r;L Specifications <br /> {"1 Public Fl Other 0 Depth of Grout Seal is Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed byTSPe� r7i <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth �G^� ��15gs: W <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public 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 is depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Weil Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/sire <br /> FILTER BED 1=1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <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 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 California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: C CA ?l0. ?i43 3 22 _ Date: f3 y�1't 9a <br /> FOR DEPARTMENT USE ONLY <br /> d, ftApplication Accepted by Dat '- i^96 <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection bv�d�4 Date2-7,L3-9D <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 /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . <br /> EH 53-241REV.iIx51 <br /> EH.a-Ie c-y � <br />