Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 , <br /> O BOX 2009, STOCgTON, CA 95201 <br /> pERg T EXP IBES 1 Y R N DTE S <br /> Triplicate) <br /> (Complete in p <br /> Application is hereby made to San Joaquin County fora t <br /> Permit to construct and/or install the work herein describelations . Sans <br /> •liance,lrith Ban Joaquin County Ordinance No. 549 and 1862 a.nd the Rules end Regu <br /> application is made in camp <br /> Joaquin County Public Health Services. Lot Size/Acreage <br /> City <br /> Job Address Phone <br /> r <br /> __ /� <br /> Owner's Name `f...3-76�/ Phone�u f} <br /> -"` rum License No. -� <br /> ddress W p@STRUCT{ON ❑ Out of Service Well ❑ <br /> Conllactor WELL LACEMENT n Monitoring Well <br /> NEW WELL ❑ OTHER ❑ <br /> TYPE Of WELLlPUMP: SYSTEM REPAIR ❑ <br /> 1 PUMP INSTALLATION ❑ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 1 �- _-.- <br /> DISTANCE TO NEAREST: SEPTIC TANK ,-�� AGRICULTURE,WELL. OTHER WELL--- pITSISUMPS <br /> FOUNDATION - � <br /> TYPE OF WELL' PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> I INTENDED USE 1'�-�RE Dia. of Well Excavation <br /> 4 ❑ Open Bottom ❑`Manteca Specifications <br /> CJ Industrial ❑ Tracy - . Type o�Casing-------- <br /> %Cl Domestic/Private ❑ Gravel Pack Type of Grout <br /> '•- fl Delta �Dep[h-nf Grout-Seal i r,� <br /> 1.1 Public CT Other <br /> V <br /> "-. <br /> r I lrrigatbn <br /> —.Approx. Dapth,.4.1.Eastern Surface Seal Installs <br /> �'H:P State Work Done_ <br /> Type of Pump -��- <br /> { pep&-work Done C7 Selling lyterial i Depth <br /> f. Well Destruction t U Wali Diameter -- Filler Materiai i Depth <br /> y ` Depth <br /> ` .mined if public sewer is <br /> available within 200,feet.i <br /> �. TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITI4N DESTRUCTION I 1 {No septic_systein pe <br /> Installation will served_Residence� ,Commercial Other <br /> Number of living units: -4- o1 bedrooms 1 Water table depth <br /> Character of soil to a depth of 3 feet: }` CaPaci'ty=_� No. Compartments <br /> SEPTIC TANK = ❑ Type/Mfg ` , Method of Disposal <br /> 444 >PKG. TREATMENT PLT.❑ - } <br /> ,� Distance to nearest: Well <br /> Foun ation Property Line <br /> Total fengthlsize Q <br /> LEACHING LINE 0 No. b Length of lines ;Property-Line <br /> 'FILTER BED <br /> ❑ Distanci to nearest: well, �� Foundation <br /> 1 I Depth � � <br /> `SEEPAGE PITS r t -- Property Lina -- <br /> SUMPS LI Disti ce to nearest Well Foundation �t <br /> DISPOSAL PONDS ❑ <br /> l hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, statelaws. and <br /> I �tulas+nd regulations of the San Joaquin County <br /> Home owner it licensed agent's signature certif'�as the following: "I certify that in the performance of the work for which this permi[is issusd9l signatUFO <br /> shah not <br /> 4 employ the person in such <br /> l candy man er . he De man asubjeto becomecof the wok 10 whict to workman** h thea tpermition yis issued,Calif of shall employ persons rnia." Contractor's lsubj sring ubject to worktman'&compansa <br /> ce ng: •• <br /> tion laws of California." <br /> st call•.tor of uired,inspeptions. Complete drawing on reverse side. <br /> I The aPphcary teA,4,� Title: <br /> Signed b, <br /> FOR DEPARTMENT USE ONLY <br /> , a ` . <br /> Dots Are <br /> �, <br /> Application Accepted by y <br /> ',eA Final inspection by <br /> Data <br /> PM p+o <br /> or Grout Instion b ate -' <br /> Additional Comments: <br /> I <br /> Return all copies to: County Health Services <br /> Applicant ealtb Permi /SeryicB <br /> nvironmena <br /> 445 N�San Joaquin, P O Sox-2000 Stkn, CA 95201 <br /> - - -"-" _ w <br /> PERMIT'NO, <br /> RECEIVEO IY GATE <br /> FEE AMpUNT OUE AMOUNT REMITTED CASH <br /> 4 INFO' <br /> +.EH 13-34IREV.tina� <br /> EH 1•"1e <br />