Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2049, STOCKT ON, CA 95201 <br /> (209) 468-31447 <br /> PERMIT EXPIRES 1, YEAR f119 M_D_ATE IS59 I- r' <br /> (Complete in Triplicate) <br /> I Application is hereby Isade,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 16 ?7h-+LE t�3 kCity <br /> Lot Size/Acreage <br /> L/Le.r t-C/1 PhoneOwner's hame f�� � � /� Address � } t <br /> f Contractor '?6Ss /t'�'>'11Ai Address 3 ��► �I nC6IN , License No. ��Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTALICTIONA Out of Service.Nell C1 <br /> PUMP INSTLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> ALL7 <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES J DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSlSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f.T Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications �I� <br /> 13 Public 1�1 Other ❑ Delta Depth of Grout Seal Type of Grout �J <br /> G Irrigation —Approx. Depth 0 Eastern Surface Saul Installed by <br /> Repair Work Done U Type of Pump H,P, k Stat Work Done <br /> Weil Destruction O Wait Diameter �� Sealing Material 'i Depth <br /> iLl <br /> Depth �e Filler Material &i-Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION L7 DESTRUCTION 0 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms 1j <br /> Character of soil to a depth of 3 feet:1 Water table depth <br /> SEPTIC TANK. 0 Type/Mfg) Capacity m <br /> No. Compartents <br /> r PKG. TREATMENT PLT,El 1, Method of.Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Propeny Line <br /> SEEPAGE PITS i I Depth I Sire 4M Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <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 f�. <br /> P Home owner or licensed agent's signature canities the following: "1 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 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." r G <br /> The applicant m call fo required inspections. Complete drawing on reverse fide, <br /> Signe T itis: Date: <br /> � <br /> E L <br /> FOR EPARTfNENT USE ONLY / <br /> Application Accepted byIFDate F!�] Area <br /> Pit or Grout Inspection by Date Fintl <br /> t 'w Inspection by Date 10"1(0-9 Z <br /> I <br /> Additlonal Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC H L;;TH SERVICES i1P Pfpe <br /> ENVIRONMENTAL HEALTH DIVISIONFpERYIT/SERVICES <br /> 448 N SAN JOAQUIN, P O BOX 2008, STOCKTON. CA 85201 <br /> FEE AMOUNT DUE. AMOUNT REMITTED CK RECEIVfo BY DATE PERMIT'NO. <br /> INFO <br /> . Em 13.241It".I/M5) gip - 1,57 <br /> f Eli i�•2a <br />