Laserfiche WebLink
t� <br />�t- <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />3.601 E. HAZELTON AVE., PHONE (209)46$-3420 <br />P O BOX 2009, STOCKTON, CA 95201 <br />RERMIT EXPIRES 1 YEAR FROM DATE ISSUED . <br />(Complete in Triplicate) <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br />application is made in cott>pliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br />Joaquin County Public Health Services. <br />Job Address - i • E , QR}q I�:t�} <br />, City Lot Size/Acreage <br />Owner's Name I� L�_ Address 1� E • t �?Q Q� . Phone 0'-10 <br />Contractor4 11f1.a License No. Address O o R, 0� d, ��$�Z Phone ' �Jr <br />TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br />PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well. ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br />t <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s <br />C) Industrial ❑ Open Bottom ❑ Manteca Dia: of Well Excavation Dia. of Wall Casing I <br />F1 Domestic/ Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br />I'1 Public n Other l fl pelta th of Grout Seal :Type of Grour <br />I I Irrigalion _ Approx. Depth I I Eastern 541tgace Seal Installed by . <br />Repair Work Done Ll Type of Pump H. P. ' State Work Done _ <br />Well Destruction ❑ Well Diameter ---Se811ng Material <br />Depth _Filler Material d Depth <br />TYPE OKS_EPTIC WORT: NEW INSTALLATION I 1 REPAIR/ADDITION-la DESTRUCTION I I INo septic system permitted if public sewer is <br />t _ r available within 200 feet.I <br />Installation will serve: Residence" v Commercial Other4fDi�'� <br />Number Imiwng, units: L Ngmber o edrooms. � r` <br />Character of'soil to,a depth of 3 feet'. Water table depth <br />SEPTIC TANK 'i T ` /Mi r t' Q� <br />�+� YPe g <br />Capacity -11(2-0 _ Q No, Compartments <br />PKG. TREATMENT PLT. ❑ A t' `� f Method of Disposal <br />r <br />vJl 't Distance to nearest: Well �� ° Foundation _LQ _ Property Line <br />J i <br />LEACHING LINE, 0 No: & Length of lines Total length/size <br />r <br />FILTER BEI)J ' ` EJ 'Distance to nearest,, I Well Foundation Property Line <br />SEEPAGE.PITSv_II Depth Sizer Number <br />SUMPS Cl Distance to nearest: Well Y _ " Foundation Property Line <br />DISPOSAL PONDS Cl l <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 thit in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- <br />tion laws of California." <br />The applicant t call fo I req fired inspections. Complete drawing on reverse s' e <br />Signed X Title' r r _ Date: <br />�. <br />FO pEPAR�TM�EN'r USE ONLY <br />Application Accepted by Gt �,_ k'� Ir- .�Date ryj—� Area 0 Z-- Z <br />Pit or Grout InsFaction by Date Final Inspection bT_i )' Vl Date `t <br />Additional Comments: <br />Applicant -'Return a1S copies to: Sam Joaquin County Public Health <br />Services, Environmental Health Perritt/Services <br />1601 E. Haaelton Ave., P 0 Box 2009, Stockton, CA 95201 <br />. EN 132r Ir+EV, 1/ns> <br />EH 14.20 <br />FEE <br />INFO <br />'AMOUNT DUE <br />A!AOUNT REMITTED <br />K d <br />CASH <br />RECEIVED BY <br />NO. <br />�/ <br />C7 <br />%DATE <br />�.O <br />�gPERMIT <br />-9 l�Ar,07 <br />o <br />