Laserfiche WebLink
IN <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)466-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> 1D RES Y- R FROkf DTE 7SSntizn <br /> (Complete in Triplicate) <br /> A"Plica+ion is hereby Grade to San Joaquin County for a permit to construct and/or install the vork herein described, This <br /> "Plication ie Cade in eom> liance with Sao Joaquin County Ordinance Ro. 5119 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> Job Address 5448 N E ' City-ZtQ=k±MM Lot Size/Acreage <br /> Owner's Name._.Wick I and Prvnp.•r} _ Address I 7 <br /> Phone <br /> Conbactor Hzta1<- F5 1� „ 95650 95015 <br /> rLtrxL11L.� Address%'•=7 .�:st m? �+1 � ��i� r n License ND. a <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL AEPLACEhtEN7 C7 in,5'r 5� phone t ra t <br /> DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPArR 0 OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK Pl rl SEWER LINES SU 0 <br /> FOUNDATION .` DISPOSAL FL0.�1` PROP. LINE �,��prp <br /> { WELL OTHER WE45 "tom <br /> AGRICULTURE WELL i:R1 PITS/SUMPS S !I <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS �() <br /> ❑.Industrial ❑Open~ Bpnorn� ❑Manteca Dia.of Well Excavation <br /> Cl DOmaS1iC(Priyale 0 Gravel Pack ❑TracDia.Of Well Casing <br /> y Type of Casing ' r <br /> ('I PSpecilications <br /> ubriO 1:]Other FI calla Depth of Grout Seal 15 <br /> I I Irri anon Type of Group <br /> U' —Approx.Depth II Eastern Surface Seallnstauud by <br /> Repair Work Done LJ Typo of Pump H.P. <br /> Wali Destruction ❑ Well Diameter Sealing Material d Depth State Work Done_ <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATrON I 1 REPAIR/ADDITION I! DESTRUCTION I I {No septic system permitted it public sewer is <br /> Installation will serve: Residence^ Commercial_ Other available within 200 feet.} <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> 0 Type/Mfg Capacity— No.Compartments <br /> N'd.TREATMENT PLT.C1 <br /> Distance to nearest: WellMethod of Disposal <br /> Foundation Property Line <br /> LEACHING LINE Cl No.8 Length of lines <br /> Total longth/sine <br /> FILTER BED <br /> C] Distance to nearest: Well <br /> Foundation. Property Line . <br /> SEEPAGE PITSp <br /> SI I Depth "_,Sire <br /> UMPS Number <br /> LI Distance:o nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Lina <br /> I hereby regal that f have"Spared this application ion and that the work will be done in accordance wilh San Joaquin county ordinances,state laws,and <br /> rules and regulations o}the San Joaquin County I <br /> Home owner or licensed agent's signature certifies the following:"1 certify that in the performance of the work for which this <br /> employ any person in such runner as to become subject to workman's compensation laws of California.' Contractor s hiring o�sub-contracting rmit is issued,lsignaltu et <br /> California.- <br /> certifies the following:"I certify that in rho per1c ante of the work for which this permit is issued,I shall employ tion laws of California." p P Y persom cubject to workman's compensa• <br /> The appl]cant must a ,or all require(]ins ions.C mplete drawing on reverse side. <br /> Signed <br /> Title. Wil• <br /> t — Date: `38 991 <br /> f FOR DEPARTMENT USE ONLY <br /> APPScstlon Accepted by ! / <br /> Date �� Alas r 7 <br /> Pit or Grout Inspection by Data <br /> Find Inspection by nets <br /> � L%dd'nbrtd Comments-. <br /> Ilpplicaat- <br /> Return all copies-to:-6nn JOnQuin County Public Health <br /> Services, Ehvirotu.ental Realih Permit/Services <br /> 1601 E. Raselton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> NFO AMOUNT DUE AMOUNT REMITTED <br /> INFO '-CASH'- RECEIVED BY GATE PFRMI7"NO. - - <br /> .EK t3-I4 IREV.Ions) <br /> fH 114e , i - <br /> rI <br />