Laserfiche WebLink
APPLICATION FOR PERMIT <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAH F&QM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct end/or install the work herein described. This <br /> application 1s made in ectiliance with :San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Jos4uin County Public Health Services. <br /> ob Address Cit Lot Size/Acreage <br /> 1111 Owner's Na D u dress _1'. b1U <br /> �' b Phon4-Oli <br /> Tractor �ObeVkA re l Address 13C11WZYdA License No.. <br /> TYPE OF WELL/PUMP: NEW WELL°❑ WELL REPLACEMENT 17 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION'[]" SYSTEM REPAIR ❑ - " . OTHER ❑ t14onitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATION AGRICULTURE-WELL­ LOTHER-WELL --PITS/"SUMPS _ <br /> INTENDED USE "TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4Q <br /> C1 Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> rl Domestic/Private ❑ Gravel Pack E7 Tracy Type of Easing_ Specifications <br /> I'I Public C] Other FI Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _"Approx. Depth I I Eastern Surface Said lnstalled b_y <br /> Repair Work Done U Type of Pump H,P. State Work Done <br /> i <br /> Well Destruction ❑ Weft Material Depth <br /> f Diameter �•" <br /> Depth biller Material i Depth I ' De e rP A tt <br /> � <br /> f ev <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION.l 1 REPAIRIADDITION i I DESTRUCTION (No septic system permitted if public setrie►is <br /> r w available v3ithin'200 feet.l <br /> Installation will some: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soll 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 /> LEACHING-LINE -=No:-& Length-of-lines— ..Total length/size -- a <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line i <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: " Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hareby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> fulas 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 Ghali not <br /> employ any parson in such manner as to become subject 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." <br /> The applicant must If aN rr Z <br /> ins coons. Complete drawing on reverse side. ! ' <br /> �, x212/ fi��{ 1 0 Ttle Date: <br /> F R DEPARTMENT USE ONLY q <br /> Application Accepted by Date {"a^'� 4-= Z—— Area <br /> Pit or Grout Inspection by Date II Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: Ban Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17"N0. <br /> INF((O�� <br /> . EH 13-44IREV.rix5l <br /> EH 14.25 <br />