Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTYNPUBLIC HEALTH SERVICES <br /> ±_ <br /> ENV I RONMENTAI,'HEALTH DIVISION <br /> P O BOX 2�Q9; 8t0dKTON, CA 95201 <br /> 4 4V (209) 468-3447 <br /> E%P_IRFS- x XM PROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein,deacribed. Thia <br /> application is made in cottgiliaace with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulatione of Ban <br /> Joaquin County Public Health Services, +J <br /> Job Address 700 '5' 4 //�zo tt �I City Size/Acreage <br /> Owner's Nama�Msq aT V G111� Address O ry Phone <br /> Contraclor _ Iu ✓ML ddress Z icense No, /L�3 Phone 4462 <br /> TYPE OF RL/PUMP:v ` •.s W,'ANEW WELL 11 , � WELL REPLACEMENT DESTRUCTION t of Service well ❑ <br /> PUMP INSTALIATION—R� T SYSTEM-REPAIR•❑— �OT�HE�R ❑ Monitorin$Well <br /> � E� <br /> DISTANCE TO NEAREST: SEPTIC TANK &4 SEWER LINES — DISPOSAL FLD, �Y P'T/ S IPROP. LINE + <br /> FOUNDATION �� AGRICULTURE WELL OTHER WELL PITS/SUMPS ej. j <br /> INTENDED USE TYPE OF WELL PROS M AREA CONSTRUCTION SPECtFICATIO S _ r <br /> 177 Industrial O Open Bottom anteca 1 Dia, of Well Excavation Dia. of Well Casin �J <br /> �mestic/Private I�rtsravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public Cl Other ❑ Delta Depth of GMsouc,Seal ' 0 Ty 01 Grout <br /> 0 fr6gation —Approx. Oopth 0 E stern Surface Saul Installed by / ' O <br /> Repair Work Done Type of Pump H.P. _ IState,Work Clone ._ <br /> Well Destruction Well Diameter Sealing Material i Depth P1 irt� V <br /> Depth / Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION CJ REPAIR/ADOITION 71 DESTRUCTION G IN, septic system permitted if public sewer is s <br /> available within 200 feet.I <br /> Installation will serve: Residence Commercial,--.,_• Ocher <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ i Method of Disposal <br /> Distance to nearest of Foundation Property Line ! <br /> LEACHING LINT: iC1 No. & Length of lines Total length/size J <br /> V r <br /> FILTER BED '❑ ' Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth4 . Sire Number <br /> SUMPS LI Distanco o nes ,st: "d-Well yEoundation "i. r Property Line <br /> DISPOSAL PONDS ❑ .� ='� LL I <br /> I hereby cenity that I have prepared this application and that the work will be dans in accordance with San Joaquin county ordinances, state laws, and j <br /> rules andraguiatio San Joaquin County l <br /> Home owner or ensed age 's signature certifies the following; "I certify,thavin the performance of the work for which this permit is issued, 1 shall not <br /> employ any son in such ma ner as to beco a subject I rkrnan's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the ollowing: "I certi that in t a ncs,9W1Vwork for which-this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws Califor a." i <br /> The apps' ant a f all.req a e. <br /> Signed Title : !Z%6 Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date n� 2— Area -Okla <br /> Grout <br /> Pit r nspectlon by Date f Z Final Inspection b EEZDat4� i <br /> Additional Comments <br /> Applicant — Return all copies to: SAN J AQUIN COUNTY PUBLIC HEALTH d SentC �lr <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> C444\/ 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201CK 9 <br /> aws�e r <br /> IEEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE pPEAM17'sN�o. <br /> + EN 13.24 MIN.�iKel <br /> P 1 00 1, C?, �� e-k 9 2-- 2 -a 90 <br />