Laserfiche WebLink
APPLICATION FOR PERMIT <br /> w SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t <br /> ENVIRON][SNTAL HEALTH DIVISION No G� <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> t P O BOX 2009, STOCKTON, CA 95201 <br /> u R <br /> RMIT IRE 1 Y FRO1[ DATE Ig.SUED N-ow <br /> (Complete in Triplicate) <br /> f Application is hereby made to SanJoaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cmVliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> fl( Job Address City._ 7'j _KN Lot Size/Acreage <br /> X\ wer's Name L AddressZ S`3 S8 h7 O S�' . /1116,R_ <br /> Phon o <br /> Onlractor Address License No. <br /> C . Phone <br /> 'TY-PE OF WELL/PUMP:: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST.-SEP-TIC-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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Welt Excavation Dia. of Well Casing <br /> n Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casio � <br /> g Specifications"-._ <br /> I'I Public ' 171 Other - 'f_1 Delta Depth'of Grout Seal Type of Grout f j� <br /> I I Irrigation _.Approx. Depth. I t Eastern Surface Seal Installed by LJ <br /> Repair Work Done 0 Type of Pump l 'H.P. State Work Done r <br /> Welt Destruction ❑ Well Diameter ' Sealing Material-A-Depth <br /> Depth r Filler Material i Depth -� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted it public sewer is <br /> 013 <br /> available within 200 feet.! <br /> Installation will serve: Residence _ i Commircial_ Other , <br /> Number of living units: Number of bedrooms <br /> Character of Bog to a depth of 3 feet- Water table depth 1 <br /> SEPTIC TANK. r 1 ❑ Type/Mfg I Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Dispose{ <br /> Distance tonearest: Well Foundation Property Lina <br /> LEACHING LINE �4C1"Na.If Length of lines" <br /> Total length/size <br /> FILTER BED E) Distance to nearest: Well Foundation - Property line O <br /> SEEPAGE PITS I I Depth Size Number~ <br /> SUMPS Cl Distance to nearest: Well -Foundation Property Lira <br /> DISPOSAL PONDS ❑ <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 Y <br /> rules and regulations of the Sen 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, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:1 Certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compenss• <br /> tion laws of California." <br /> XS <br /> Tha applicant mus fo all required i ctions. Complete drawing on reverse side,tgnedC� /L u® Title: Date- <br /> 0 Z-1 EPARTMENT USE ONLY <br /> Application Accepted byr6t__ lk"l-, -�Z_.. <br /> -'-Date Area <br /> Pit or Grout Inspection by i Date / <br /> / Final Inspection by Data � Ztl�g2� , <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Servicesf��• <br /> +rCI <br /> " Environmental Health Permit/Services r�Q. lVt„�, <br /> - <br /> 446-N San Joaquin, P O Box 2009, Stkn, CA 95201V <br /> FEE AMOUNT OtJE AMOUNT REMITTfO <br /> INFO CASH ECEIVEO BY O TE PERMiT'N0. <br /> f <br /> . EN 13-24(REV.I/A 51 � y <br /> EH t6a6 t O i.J � � <br /> I <br />