Laserfiche WebLink
~' APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> p O BOX 2009, STOCKTON# CA 95201 <br /> (209) 468-3447 <br /> Y R <br /> �. <br /> (Complete in Triplicate) <br /> made to San.Joaquin County for a permit to construct and/or install the work herein dearribed. This <br /> i app in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> JoaqurnmejumpEw7mllublic Health Services. <br /> �A�N fir- City S7XNr Lot Size/Acreage <br /> Job Address � - y <br /> 51¢TJpG Phone <br /> Owner's Name ,S yE LUE Address. J. <br /> T rt y <br /> A��4 ,e7 —Vela. 76 _ 1 h <br /> License No. 'Zjaone `�.f �R7 <br /> Contractor�� -Address A✓ <br /> NEW WELL ❑ WELL REPLACEMENT - DESTRUCTION ❑ Out of Service Nell ❑ <br /> TYPE OF WELL/PUMP: T. OTHER ❑ Monitoring Well CZ <br /> ! PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK._ SEWER L E5 PITS/SUMPS <br /> FOUNDATION — AGRICU URE WELL OTHER WELL_ <br /> INTENDED USE TYPE OF WELL PROBLEM ARE CONSTR ION SPECIFICATIONS Dia. of Well Casing <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. Well Excavation Specifications <br /> U Domestic/Private ❑ Gravel Pack C] Tracy pe of Casin g Type a} Grout <br /> ❑ Public !1 Other I ❑ Delta epth of Grout Seal _ R <br /> GI Irrigation �..Approc Depth C3 Easter t S ace SemiInstalled by <br /> H P State Work Done, <br /> Repair Work Done U Type of Pump Sealing Mate sal i Depth <br /> Well Destruction ❑ Well Diameter filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITiON 0 DESTRUCTION G (No septic shin system permfeatit)ed if public sewer is <br /> f <br /> + Installation will serve: Residence Commercial— Other <br /> ! Number of living units: _-Z- Number of bedrooms --.-- <br /> ff[ Character of soil to a depth of 3 feel: Q' Water table depth <br /> SEPTIC TANK [9�Type/iulfg _ C 4 - Capacity /2-o d Na. Compartments Z <br /> PKG. TREATMENT PLT. Q Method of Disposal 0 <br /> r � f <br /> Distance�to nearest: Well Foundation Property Line �� - <br /> LEACHING LINE Or No. S Length of lines . 6-g Total length/size 74 <br /> ' Foundation _ �o_� Property Line <br /> FILTER BED n Distance to nearest: Watt <br /> ;4 <br /> - Number ' <br /> i SEEPAGE PITS l Depth l a3-- /- _Sire O s <br /> SUMPS' Ll Distance to nearest: Well /ag2 Foundation Z --!t- Property Line .- <br /> DISPOSAL PONDS ❑ <br /> - <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 of subcontracting 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 componss- <br /> tion Iowa of California." r <br /> The applicant must call for all required inspeptions, Complete drawing on reverse side. { <br /> Date: k- 2 0 <br /> Signed t Title:FOR DEPARTMENT USE ONLY Z <br /> f -7 / <br /> Date ,/ /` Area <br /> 1�02 1 r <br /> Application Accepted by �p <br /> Data �� a <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: t _ <br /> Applicant - Return all copies to-' SAN JOAQUIN COUNTY PUBLICdREALTR 86RVICES N ' <br /> r-4 45 N <br /> IOSAN JOAQUIN,TP 0 BOX I2009,ON PERMIT/SERVICES <br /> CA 86201 <br /> a, .1 <br /> I <br /> FEE CK RECEIVED SY DATE "R 'iF 0AMOUNT DUE AMOVNT REMITTED CASH <br /> . EH 13•74 I11Ey.r/A ss � � �� <br /> EH '.4.24 r <br />