Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH S ICS <br /> ENVIRONMENTAL HEALTH DIVI OfF <br /> 445 N SAN JOAQUIN, PHONE D14 <br /> �yQ4 C <br /> 2� P O BOX 2009, STOCKTON, CA $$�{� xxxxxx-y3 S" moi. <br /> PERMIT BUIRES I YEAR FR �� <br /> (Complete in Triplicat )ItNV <br /> Application is hereby node to San Joaquin County for a permit to construct ar, 1 V be eln described. e <br /> application in Wade 1n compliance with Sao Joaquin County Ordinance No. 549 and 1862 one of San <br /> Joaquin county Public Health services. / ��,J <br /> Job Aridness ale • / V 6 9 �l X,/Pyey ��• City Srdbyr/.� Lot Size/Acreese ACY� <br /> Owner's Name <br /> /� ee,r�*rd V! f YYA Address Swale Phone <br /> A <br /> Contractor mrAw/J 5niy Address OAb; /p6vV&1A7 /1�0 License No. yyPhone AX3-IVl/ 3 <br /> TYPE OF WELLIPUMP, NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION ❑ Out of Betake Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C slonitorintg 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 /> ❑ Industrial C Open Bottom ❑ Manteca Die, of Well Excavation_ Dia. of Wag Casing <br /> C Domist ip.(Privato C Gravel Paco ❑ Tracy Type of Casing_ Slnctfirahons <br /> I'1 Public ❑ Other n Delle Depth.of Grout Seal Type of Grout ^ <br /> 1 I Ingadon _Approx. Depth 11 Eastern Hudson Senl Inatetled W <br /> C <br /> Repair Work Done C Type of Pump H.P. State Work Dona _ <br /> Wall Destruction ❑ wall Diameter Sealing Material a Depth <br /> Depth Tiller Material F. Depth <br /> TYPE OF SEPTIC YpORK:.. NEW INSTALLATION I.1 REPAIR/ADOITION IO DESTRUCTION I I (No septic system permitted it public sewer in t <br /> available within 200 lest.) I <br /> Inataaltion will1 e: Residents Commercial_ Other <br /> Number of living unite: Number of bedrooms E. t <br /> Character o1 I"to a depth of 3 het: G L w�r Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartment <br /> PKG. TREATMENT PLT.❑ t,Method of Disposal <br /> Distance Io nearest: Weal - Foundation _ Propeity Line <br /> LEACHING LINE RI No, b Length of linea yo r Total length/size <br /> FILTER BED C Distance to rarest: Well,J � Foundation _ Property Line 7q' <br /> SEEPAGE PITS a Depth 'Z-�r _Sita_ YX ^' *leg Number. / <br /> SUMPS LI Distrtca to morsel; Well -200' 'Foundation �� � Progwly Lina <br /> DISPOSAL PONDS ❑ 7 <br /> I hereby certify, that I have prepared this application and that the work wild.bs Aons in oceadante with yah Joaquin county ordinances, stats laws, and <br /> rube and regulation of the San Joaquin County <br /> Horth owner or licensed agent's signature o nilies the following: "t certify that in the performance o1 the work for which this permit is issued, 1 shall not <br /> empty any parson M such mammon as to bescoma subject to workman's compensation taws of California."Contractor's hiring or sub-contracting signature <br /> canifles the f I artily,Wit in the portatmance of the work for whk;h this parmil is issued, 1 shall employ paroory sub)ect to workman's compenN- <br /> tion laws of C&Wfo, .. <br /> This applicant must ra111Or aN required inspections. Complete drawing on reverse side. <br /> Signed X Title: Dat: <br /> FOR DEPARTMENT USE ONLY {{OqE <br /> Application Atxeptad W _y Dat <br /> t Iropecuon br Date 'f Fiml lmpacpcn by <br /> C'txstmertt: <br /> APTlicant - Return all copies to: San Joaquin County Public Health Services -'- <br /> \, Environsental Health Perolt/Servlces <br /> 445 N San Joaquin, P O Box 1009, Stkn, CA 9 01 <br /> AMOUNT DUE AMOUNT R n <br /> nTED /(/C,A/,H1H RECENED BY .OATE- <br /> . FNt}an laN.veei •.iv i Il • A/ D` -.. <br /> EN loos 1 y V J <br />