Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONIMTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOC&ON, CA 85201 <br /> (209) 468-3447 <br /> PERMIT-EXPIR116 I XAAR IPM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby r:ssde 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 end 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address P City Lot Bile/Acreage <br /> Owner's Name �'n�. 7 dna l_ j VC4Y Address _ 622�6 5 s C�' s2 M Phone Lq2 ' <br /> Contractor e L Address --_��' _ _License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION C out of Service Neil Gl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPE6FI,CATIOW <br /> n Industriel'. ❑Open Bottom ❑ Manteca Diu.-of-MJdiIDia, of Wen Casing <br /> U Domestic/Private ❑ Gravel Pack C]Trac Type of Casing Y YP g Specifications <br /> M Public Cl other ❑ Delta Depth of Grout Seal_ Type of Grout <br /> 0 Irrigation ­Approx. Depth 0 Eastern SuA'a`cy—Sea 1.1ittillied'tfy` <br /> Repair Work Dona U Type of Pump H.P. Stara Work Done _ <br /> Well Destruction... O Well Diameter Sealing Materi ',li'Dept7�" ' -- •, _,�- "-- <br /> { Depth Filler Material"i <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADO!TION CI DESTRUCTION CJ IND septic_sy-stem permitted it public sower is ' <br /> ` - �ovailsbie within 200 resl.l <br /> Installation will serve: Residence��Commercial__Other / <br /> I. Number dt living units: " Number of bedrooms "f <br /> Character of @oil to a depth of 3 feet: <br /> 'Water tabT depth 2 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 .f ! i'Method-of Disposal <br /> Distance to nearest: We11 �Fovndetion. Property Line <br /> -r <br /> LEACHING LINE fe Nb. & Length of linea' '` Total lengthhim � _. <br /> FILTER BED L?DWanca to nearest: :'} Wei) Foundation Property Line - <br /> SEEPAGE PITS I I Depth sem" Sire Number <br /> SUMPS CI Di@tsnca to neer est: 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, and` <br /> rules and regulations of the Sen Joaquin County <br /> Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued,I shall not <br /> employ any person in such Mannar as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> y cattifies the followings'•I certify that in the performance of the work for which this permit is issued,I shall employ persons Subject to workman's componsa- <br /> ilon laws of California.,, <br /> The applicant n1val call for all required speetions. Complete drawing on revers*side'. <br /> Signed Title: ._ ,( Date:' / V <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 2 �04 Area 12/4 <br /> Pit or Grout Inspection by Date Final.Inspection by Dae� D <br /> Additional Comments: <br /> Applicant - Return all copies•tos SAN JOAQUIN COUNTY PUBLIC HEALTH BERVICSB <br /> ENVIRONMENTAL HEALTH DIVISION pERYIT/SBRYICES <br /> 445 N SAN JOAQUIN. p O BOX 2009, STOCKTON, CA 95202 <br /> FEE INFO AMOUNTDUE AMOUNT REMITTED CIFASS4 I AiCEEVEO BYDATE I PERMIT'NO. <br />