Laserfiche WebLink
APPLICATION ? �ff <br /> SAN JOENVIRONMENTALCOUNTY HEALTH D <br /> PUBLIC <br /> S <br /> L �wICES `n7� pJ gry <br /> 445 N SAN JOAQUIN, PHONE (20 ) 420 'Kl ') O <br /> P O BOX 2009, STOCKTON, C —A1D 4p T <br /> RERMIT EXPIRES 1 YEAR FR M D ttfin <br /> (Complete in Triplicate) <br /> Application is hereby made to Sao Joaquin County for a permit to construct and/or,lm yyy_y�y 'This <br /> application to made in cotgrliance vith Ban Joaquin County Ordinance No. 549 and 1862 and the Rules m egu one of San <br /> Joaquin County Public Health Services. P <br /> Job Address `- 11 k I A 2 r OX Vc • _ Gw6�n � Lot Site/Acreage <br /> Owner's Name L� r "'T'e''�/jg.�ddr(e�ss- ?T�j11 ,� f( �Q��Pyhone - /�4 I <br /> Contractor�y r-1UKl�'-711'X Addresi;9L Gam( 1Q G License No[:'"M Phone - .s <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT 171 DESTRUCTION O Out of Service Nell O <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER O Monitoring Well LT <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 /> f I Industrial O Open Bottom O Manteca Dia, of Well Excavation Dia. of Well Casing <br /> f I Domestic/Private O Gravel Pack I-) Tracy Type of Casing_ ___ Specifications <br /> I"I Puhlic 1.1 Other Il Delta Depth of Grout Seal Type of GrouT OQ <br /> 1 I Inglanlon __ Approx. Depth I I Eastern Surface Seal Installed by <br /> Rspsir Work Done U Type of Pump H.P. _ State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material a Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will se": Residence _ Commercial* Other <br /> Number of living unite _ Number of bedrooms <br /> Character of soil to a depth of 3 feet ( Waist table depth _ <br /> SEPTIC TANK O Type/Mfg - s Capacity It?DD No. Compartments <br /> PKG. TREATMENT PLL O AITi Or, (,(�/�l -Method of <br /> Dirsal <br /> Distance to merest: Well Foundations Property Line <br /> LEACHING LINE Y No. b Length of lines Total length/size le of, <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line _ <br /> SEEPAGE PITS kf Depth at= Size � Number <br /> SUMPS LI Distance to merest: Well Foundation <br /> SZ'{L Property Lim <br /> DISPOSAL PONDS O <br /> 1 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 San Joaquin County <br /> Home owner or licensed agent's signature Canities 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 tanner as to become subject to workman's compensation Iowa of California." Contractor's hiring or subcontracting signature <br /> certifies the foll no. "1 certify that in the performance of the work for which this permit is issued, 1 shell employ persons subject to workman's componsa <br /> tion laws of G lif mis." <br /> The applicant at call to a factinspections. Complete drawin yeet" safe. Q <br /> Signed pill TitleDate: <br /> 1/'� FOR DEPARTMENT USE ONLY <br /> Application Accepted by lea Date -3 Area <br /> Pit or Grout Inspection (/ Date Final Impectio by Date <br /> Additional Comments: <br /> ApPlirnnt - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> L� NFE AMOUNT DUE AMOUNT REMITTED Ckv <br /> CASH RECEIVED BY GATE 4PEhR]MIT NO <br /> . EN II N IREv.area I l�I , UU 11q. e) C� / _Zl �,��� � �S cj /v/ 'lV <br /> " 2311 <br />