Laserfiche WebLink
APPLICATION FOR PERMIT <br /> i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES sr "' <br /> ENVIRONMENTAL HEALTH DIVISION R Eii <br /> P O BOX 2009, STOCSTON, CA 95201 J U N 12 1992 <br /> (209) 468-3447 ENVIRONMENTAL HEALTH <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 /> I application is made in Compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regul.atione of San <br /> Joaquin County Public Health <br /> Services. <br /> G Job Address t[ 7� / fly ►'�L City Lot Size/Acreage <br /> I C <br /> Owner's Name -._ Address P _ _ Phone <br /> Contraci� .�Addre�alq4&� -Gd-��GXLicense NAI(09�4-2-- Phone?55 �;�W <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL'—EPLACEMENT ❑ DESTRUCTION ❑ Out of Service well Gl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 11--" OTHER ❑ Monitoring Well C7 <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 /> C} Ind ial 0 Open Bottom C1 Manteca Dia. of Well Excavation pia. of Well Casing <br /> omestic/Private ❑ Gravel.Pack #..0 Tracy 4- Type of Casing Specifications <br /> M Public I:1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> 4 0 Ifri6ation Approx. Depth ❑ Eastern f`Surface Seal Installed by .` <br /> Repair Work Done ffllType of Pump . H.P. al.•Y� 1 State Work Done <br /> s Well Destruction 0" Well Diameter Sealing Material i Depth +� <br />' Depth Filler Material 4 Depth W <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION O—DESTRUCTION-CI-(No sep6c.system permitted if public sewer is. <br /> available within 200 feet.) <br /> Installation will server Residence J Commercial— Other ) <br /> Number of living units: Number of bedrooms , T <br /> Character of Boil to a depth of 3 feet�i Water table depth <br /> k `SEPTIC TANK 0 Type/Mf911 Capacity No. Compartments <br />' PKG. TREATMENT PLT. ❑ d ` Method of Disposal <br />' Distance to nearest: Well Foundation Property Line w - <br /> LEACHING LINE ❑ No. & Length of lines Total length/sire <br /> FILTER BED 171 Distance to nearest: Well Foundation Property Line e <br /> SEEPAGE PITS 11 Depth I Sire Number <br /> SUMPS 0 Distance tri nearest: Well Foundation Property Line <br /> DISPOSAL PONDS D <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 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." t <br /> The applicant must ca1J Lor all require,¢ i spections. Complete drawing on verse side. <br /> Signed Title: — -- _ Data: <br /> . FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date_ZAQ Z_ <br /> Additional Comments: // <br /> Applicant - Return all copies to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 95201 <br /> L <br /> FEE CK <br /> INFO AMOUNT DUE I AMOUNTflEMITTEO CA53�` RECEIVED BY DATE PERMIT'NO. <br /> . 26IREV.�iMsr <br /> CH A- f f-- <br /> EN;�2a <br /> r <br />