Laserfiche WebLink
rr .. <br /> r APPLICATION FOR PERMIT <br /> ' SAN JOAQUIN COUNTY PUBLIC HEALTH SRVICBS <br /> ENVIRONMENTAL HEALTH DIV'�'SI <br /> ' 1601 R. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOX 2009. STOCKTON, CA 95201 <br /> [ (Complete in Triplicate) <br /> 2-0 <br /> Appllcatloa 19 hereby sande to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with Sas Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> I Joaquin Coun�ty1 Public Health <br /> Et HealthServices. <br /> Job AddressTt3w&e- <br /> •- .._ City QS Trc Lot'Size/Acreage 35-mgC�,s_s <br /> e <br /> Owner's Nam;TMW11ddL+�*ML—NL+_L=?s Address 3M0 Tic �+►�c kite Phone 031(--1960 <br /> W' pp,, <br /> Contractor � Address r�• Y. License N0,029,&ST219AneC9lt. <br /> i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Q <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C) 640+-11- Cl OTHER @" Monitoring Well ❑ <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 /> C1 Industrial ❑Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> 17.1 Domestic/Private 0 Gravel Pack O Tracy Type of Casing Specifications <br /> 11 Public I"1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump <br /> H.P. State Work Dane 1 <br /> Wall Destruction O Well Diameter Sealing Material i Depth j <br /> Depth F111er Material i Depth <br /> Ir� <br /> TYPE OF SEPTIC WORK: -NEW INSTALLATION( I REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feat.] <br /> Installation w81 serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feat: Water table depth ' <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PI-T.Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line i b9 <br /> LEACHING LINE ❑ No. & Length of lines Total l0ngthlailt8 <br /> FILTER BED 0 Distance to nearest: Wall Foundation Property Line <br /> I <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ul Distance to nearest: Well Foundation Property Line <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, ander <br /> rules 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 shall not <br /> employ any parson in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> certifies the following:"I certify that in the perfarmance of the work for which this permit is issued,I shall employ persons subject to workman'■eomponsa. <br /> tion laws of California.,, <br /> The applic n ust call fol" d Inspections. Complete drawing on reverse side. <br /> tt e �c-r <br /> signed Title: - .7' Date: �D 3 �O <br /> j FOR DEPARTMENT USI:ONLY <br /> Application Accepted by Date � of� rsa 2l <br /> Pit or Grout Inspection by ata Final Inspection y f Oats Z� <br /> Additional Comments: f rp <br /> Applicant - Return all copies tot Sea Jot►qu a County Public Realtit T---G <br /> Services, l viroameatal Health li'e t Sexwicea Qc -r c, <br /> 1601 X. Hazelton Ave., P 0 Box 2009, Stockton, CA 85201 V� l•[( <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO C RECEIVED BY 'DATE PERMIT'NO. <br /> a EIS 13.24IREV.1/n51 t 0 <br /> Ek iMaS 1 � <br />