Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> p O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PEMIT E IRES 1 YEAR rM DATE I SSUNI3 <br /> Triplicate) <br /> (Complete in Trip ) <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 Public Health Services. <br /> d i��F-S, F ' '' City Lot Size/Acreage <br /> Job Address n,, .� <br /> Owner's Name <br /> OF- �1`KI" Address ,( G �� Phvne 8 (o-4� <br /> 214 <br /> ` �7�c 2rL& P� License No.51 ZZIo Phone <br /> • Cont;actar Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHERMonitoring Well G7 <br /> t "re6 BORwes. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PRO LINE E' � t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D14- <br /> M Industrial ❑ Open Bottom ❑ Manteca Die. of Welk Excavation i <br /> U Domestic/Private Ll Gravel Pack ❑ Tracy Type of Casing _� — Specifications <br /> ED Public i.1 Other ❑ Delta Depth of �� TO � Type of Grout , <br /> G Irrigation ,_.Approx, Depth 0 Eastern Surface Saul Installed by r 7/ZOI[Npb" [c� ! <br /> Repair Work Done U Type of Pump <br /> H.P. Stats Work Dona <br /> Well Destruction ❑ Well Diameter Sealing Material A Depth <br /> Depth Filler Material i Depth O <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRlADDITION 1=I. DESTRUCTION M iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence._.r. Commercial 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 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposai 1' <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No, & Length of lines Total length/size " <br /> FILTER BED C-1 Distance to nearest: Weil Foundation Property Line <br /> SEEPAGE PITS i l Depth Size Number <br /> SUMPS L1 Distance to nearesc Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I 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: "I comity 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 laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following; "I cenify that in the performance of the work tot which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of C lifornia." <br /> The applicant ust call f9f all requirep inspections. Complete drawing on reverse side. <br /> [' rn! Z2—9-Z_Signed Title: ✓� Data: <br /> FOFi D TM SE ONLY f <br /> Application Accepted by Date Area ZI _— <br /> Pit or Grout Inspection by / Date Final Inspection by Data <br /> Additional Comments: e,lec 44zen <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 PEI7'N0. <br /> INFO �7 CA�5jl1 <br /> RM <br /> CH 13-74 IREV.IIA5� 6 �f, Q(! 7-/T�Z <br /> EH:4.26 <br />