Laserfiche WebLink
4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ! ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DAIS 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 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 <br /> Public Health Services. T� �f <br /> I Job Address I 1 7.S /V 62K.Cl L/ -20 City �,�"i- Lot Size/Acreage <br /> ` Owner's Nam6 ' _A « A`g 4/ / Address S��'L Phone T �f <br /> ��Try /0 t>r 1 3 7J eS 3 Y-Y7 2 <br /> Contractor^ '"fess Address [� �/J License No Phone <br /> i TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 0 DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATIONi9C SYSTEM REPAIR ❑ _ OTHER ❑ Monitoring Well <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 /> } ustrial C Open Bottom ❑ Manteca Dia. of Well Excavation LL Dia. of Well Casing <br /> F <br /> estic/Private Cl Gravel Pack- ❑ Tracy Type of Casing �G Specifications. . <br /> Public 1-1 Other 71 Delta Depth of Grout Seal 3EF" Type of Grout__C C1WS6:L <br /> I I Irrigation 'kX'9 Approx. Depth I I Eastern - Surface Seal Installed by G ��- <br /> Repair Work Done 0 Type of Pump H.P. Z State Work Done. <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I i REPAIR/ADDITION I I DESTRUCTION I I Wo septic system permitted if public sewer is <br /> r available within 200 feet.) <br /> Installation will serve: Residence—, Commercial—/Other <br /> Other <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. ❑ / Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> I t <br /> LEACHING LINE Cl No. & Length of lines Total length/size r <br /> FILTER BED El Distance to nearest: Well Foundation` Property Line hl <br /> SEEPAGE PITS 11 Depth { Size Number <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> a DISPOSAL PONDS ❑ r <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, an <br /> rules and regulations of the San Joaquin county <br /> Horne 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 no <br /> employ any person in such manner as to become subject to workman's compensation laws of California.' Contractor's hiring or subcontracting 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 - <br /> The applicant must tali f r all r wire inspections. Complete drawing on reverse side. <br /> t <br /> 1 Signed X s Title: _G�C.eL --- _. Date: 2-ltr" no <br /> Sa� DEPARTMENT USE ONLY <br /> I Application Accepted by 1 Date fl Area I <br /> Pit or Grout Inspection by ` a �S fit <br /> Date Z / Final Inspection by � Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health , <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE UUU <br /> I INFO AMOUNT DUE AMOUNT REMITTED C t RECEIVED BY DATEc PERMIT'N0. ' 1 <br /> EEM N v3-24IREV.iias) r 0� 4 J t © c`� �a 8 17`!t7 Pa— -2-1 o W <br /> amu- ! Oe <br />