Laserfiche WebLink
APPLICATION FOR PERMIT E• ; t <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES NO(Ji <br /> ENVIRONMENTAL HEALTH DIVISION � � <br /> P 0 BOX 2009, STOCKTON, CA 95201 NO <br /> (209) 468-3447 A ' <br /> YEAR <br /> (Complete in Triplicate) <br /> Application in hereby made.to San Joaquiu 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 /> ob Address �` ,+2T�1 ` - City, 5'T1�v -- Lot size/Acreage <br /> KOwner's Name , �fl M r J�5� '� Address —220 le Phone <br /> Contractor /t1 + Address tax 1 �(J.M/h /T-_�� _License No. -�-56 Phonej F <br /> T'YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well {.3 <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 /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications C <br /> 1 Public S-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 0 Irrigation Approx, Depth 0 Eastern Surface Seal Installed by 9 ' <br /> Repair Work Done U Type of Pump H.Pk 'V <br /> Well Destruction 0 Welt Diameter Depth illEFDX <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIfi,SAR�t7 C !` � tlfjr)O�S�system permitted if public sewer is <br /> I1''NGril�I II II! VIS ��JJ Haji ithin 200 feet.l <br /> Installation will serve: Residence �,Commercial plod or Inspected <br /> Number of living units: Number of bedrooms ' <br /> Character of soil to a depth of 3 feet: , t`IVi.onm- .181 Health <br /> `'I D"i'Et <br /> Vllatar labia depth <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby cenify 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: 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 taws of California." Contractor's hiring or sub-contracting signature Y <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." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: [� ti � T '��T�3' _— Date: <br /> h 2=— <br /> NT USE ONLYApplication Accepted by .�[�. e ___ Date - Area! <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additlonal 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> . EH 13-24(REV S! Q0 ©� It <br /> �,_ -s .— o-4.36 P" I <br />