Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONhMgTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT BUIRES 1 YEAR FROM DATE _LSSURP <br /> (Complete in Triplicate) <br /> Application is hereby made to Ban Joaquin County for a permit to construct and/or install the cork 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 <br /> Public Health Services. <br /> Job Address tFPO City 41 Lot Size/Acreage <br /> 1 <br /> Owner's Nam ! �1 +��, ._.� Address � � L(✓ �� �,r.s �pr�.'kl�hon <br /> i ! <br /> Contractor �QLLCJ Address License No. Phone t <br /> TYPE Of WEL UMP NEW WELL Cl WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL- PITS/SUMPS-_ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L) industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'I Public 1:1 Other n Delta Depth of Grout Seal F• Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Soul Installed by <br /> Repair Work Done Type of Pum pa,(f ------ H.P. 2 — Stat.41 YVork D n <br /> Well Destruction ❑ Well Diameter Sealing Material A Dept <br /> Depth biller Material i Depth �f�AFXi�f �iC�� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system perrhitted it public sewer is <br /> available within 200 fbatJ <br /> Installation will serve: Residence Commercial_ Other <br /> - <br /> Number of living units: Number of bedrooms t <br /> Character of soil to a depth of 3 feet: f Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity - No. Compartments <br /> PKG. TREATMENT PLT.0 MethFIMME <br /> Distance to nearest: Well Foundation Property Li <br /> R <br /> 0 <br /> LEACHING LINE ❑ No. b Length of Mines Total length/size <br /> FILTER BED 0 Distance to nearest. Well Foundation P(opeSANnXAQUZLLWNTY <br /> SERVICES <br /> SEEPAGE PITS 11 Depth Size NumberMVIR NMENTAL HEALTH DiViSiOIN <br /> SUMPS LI 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 i <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 taws 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 ism of California." <br /> The applicant must call for al r ln"ptions. Complete drawing on reverse sici . <br /> Signed G2E ya Title: `?xl,�L/ � <br /> Date: � <br /> R DEP NLY <br /> Application Accepted by Date <br /> Pit of Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> IFEE AMOUNT DUE AMOUNT REMITTED CK IV <br /> M RECEIVED BY D T£ PERMiT'NO. <br /> EM1]-24 IREV.i i n 61 r <br /> EH"A-2a �Y- <br />