Laserfiche WebLink
r <br /> APPLICATION FOR PERMIT <br /> l r t <br />` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 : <br /> PMJT EXPIRES 1 YEAR FROM DAIS 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 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 2- S '`1�� ~ City G a Lot Size/Acreage 216 <br /> Owner's Name (Nif1 Lr RI A L 0-C K I rZF�ddress 6(.2- S Phone 921 147 <br /> Contractor n 'Lu-Nk ddress License No. Phone <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ wOTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUN 1UMGV%Mf OTHER WELL PITS/SUMPS <br /> } INTENDED USE TYPE F WE � LiM ,0—FR „ PECIFICATIONS . <br /> F- Industrial ❑ Open Bono, <br /> r ❑ M ntaca� �e Dia +of ell Excavation pia, of Well Casing I <br /> C <br /> Domestic/Private ❑ Gravel PrOrmlt oy"I' � ex liT e ffor Specifications , <br /> t <br /> (I Public i-1 Other work being owpl o eO"wedeai Type of Grout E <br /> I L irrigation _Appro�j ¢p } h tern.,�} �iSq I tailed-by Repair Work Work Done L7 Type of PuAfrr" €� � I fJ�il,��U!I _,State Work Done T �, <br /> Well Destruction ❑ Well Diameter Sealing(Material & Depth ' <br /> f Depth y Filler Material & Depth tr' � <br /> # i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION-1. I (No septic system permitted if public sewer is <br /> 1 <br /> available within 200 feet.I, <br /> Installation will serve: Residence Commercial_ Others�_ �J�+ <br /> Number of living units: Number of be moms <br /> Character of soil to a depth of 3 fest: � r Water table depth t <br /> SEPTIC TANK. J6 Type/Mfg S� Capal city— Ci to No. Compartments .� <br /> .' <br /> PKG. TREATMENT PLT ❑` S' ^ t s Method of isposal , .. <br /> ` Distance to nearest:. -Well .{`�a Foundation__ I b Property Line <br /> LEACHING LINE ❑ No. & Length of lines A2X, 72Total length/size- e. <br /> FILTER BED. Distance to nearest: Well-� W Foundation f 8A Property Line __�115 �ox, 1.2 <br /> SEEPAGE PITS 11 Depth Size ¢ Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 -L-°- ___ t <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 -shall shall <br /> employ any person in such manner as to become subject to workman's compensation laws of Cnliforriia."Coniractor's hiring or suti-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 applic t must call for all required inspections. Complete drawing on reverse side. <br /> r. <br /> Signed X i Title: - _.._ Date: 4-__fi-T <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �` L Area <br /> Pit or Grout Inspection by Date , Final Inspection by Date I <br /> Additional Comments: Ian+ ..r- <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services r <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE t <br /> INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. C <br /> EH 114-24 IAEV. /A si .off 3 5-1�.� - t� 3 <br /> EH 14.26 <br />