Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 -YEAR-PROM DATE ,ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby tsade,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cetwliance with San Joaquin County Ordinance No. 549 and,1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 1 9 a l d Ute.¢tri- �FLi ae �+ Oa y <br /> KJob Address _ +^� 'J y� City «r Lot Size/AcreageU <br /> Owner's Name �u Address C. }-kc` Phone <br /> �('� S�l� i <br /> /`(;ontractor �Pr-Address a-ZI 7 �i. U��+< License No, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE , NT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTE EPAIR ❑ OTHER O Monitoring Well o <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER INES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICUL RE LL OTHER WELL PITS/SUMPS — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS <br /> fl Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia, of Well Casing <br /> U Domestic/Private C) Gravel Pack C] Tracy Ty a of Casing Specifications �J <br /> M Public (:7 Other ❑ Delta Dept of Grout Seal Type of Grout : <br /> CI Ifrigation �.Approx. Depth 0 Eastern Surfi Seal Inslailed by <br /> Repair Work Done U Type of Pump H. State Work Done_ <br /> Well Destruction ❑ Well Diameter /sling Meteri i Depth I <br /> Depth Piller Material Depth I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION JO REPAIR/ADDITION L7 DESTRUCTION o septic system permitted if public sewer is <br /> available within 200 feet.) <br /> -� r <br /> Installatkon will serve: Residence_ Commercial t <br /> Number of living units: Number of bedrooms R E <br /> Character of s0to a depth of 3 feet: Ater table depth <br /> SEPTIC TANK ❑ Typa/MfgCape it p. Compartments <br /> PKG. TREATMENT PLT.Cl work hh '`y ffOmp16 e�ctsdtfiod of Disposal ; <br /> Distance to nearest: WeIIJ /IMF ,lda'141 Line ' <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Wolf Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number ? <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> i <br /> I hereby certify that I have prepared this application and that the work wilt 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 subiect 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 /> f�/ The applicant all for all required inspections. Complete drawing on (eve se side, f <br /> // <br /> Signed �^ 1 Q ---- <br /> g Title: eNs�--- Date: _ I C, <br /> a <br /> NIENT USE ONLY 112- <br /> 11 <br /> Application Accepted by }Date _ b- t�` Z Area L <br /> Pit of,Grout Inspection by Date Final Inspection by Date <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 2009, STOCKTON, CA 95201 <br /> CK f <br /> INFE AMOUNT DUE AMOUNT REMITTED /C7AS/HJ RECEIVED BY DATE q PER}MIT'NO. <br /> . EH t344 IREV.Iinsl 7 <br /> EH;!•ZB <br />