Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONIMTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)458-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT aEIRBS 1 YEAR FROM DATE I88I78D <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct arA/or install the work herein described. This <br /> application is noide in ceatpliance vith Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and RelpulAtions of San <br /> Joaquin County public <br /> /Health Services. <br /> Job Address - `� I Lti ' /ZC-lLfiLit��44 City / Lr toot Slze/Acreage <br /> Owners Name ' , i - ti a Address �J�/ /4 r_ A4}L ly ( i Pfione 33 s~y-7-1 <br /> ��� 6.$ox7G7 Phos. t <br /> Contract 1�C Address i License No. <br /> TYPE OF WELL/PUMP, NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION CI Out of Service well <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FI_D. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHEA WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial O Open Bonom O Manteca Die. of Walt Excavation_ Din- of Wall Casing <br /> 0 Domsetic/Arivate Cl Gfavel Pack O Tracy Type of Casing_ Specifications <br /> I') Public Cl Other n Delta Depth of Grout Seel Type of Grout <br /> t I lfri lation _Approx. Depth I I Eastern Surface Soul InstMied by <br /> Repair Work Done ❑ Type of Puma H.P. Stag Work Dons _ <br /> Wets Destruction O Welt Dlantstsr 8e1.I.ing Material A Depth <br /> Depth Tiller Material A Depth <br /> 0 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I( REt6lWADDMO DESTRUCTION I I INo septic system permitted if public sewer is <br /> evaiiable within 2W feet.) c7 <br /> Installation will serve: Reeklence Commercial Other <br /> Number of Ihnno units:_.L Number d oomil / <br /> Character of sofa to a depth of 3 fwt: ~— Water table depth <br /> SEPTIC TANK Type/Mfg L ' � Capacity J % No. Compartments <br /> PKG. TREATMENT PLT.D /� / Method of Disposal <br /> Okstana to nesrpt: Welt_a50 JC Foundation�L5 Properiv Line ! <br /> LEACHING LINE >( No. 8 Length of lines , ' " S C' Total length/site <br /> r� <br /> FILTER BED O Distance to nearest: Weis��T Foundation Inr+ _ Property Lkta 5r 7 <br /> SEEPAGE PITS i 1 Depth Size Number_ <br /> SUMPS Lt Distance to rtearast: Well Foundation Prmorty Line <br /> DISPOSAL PONOS ❑ <br /> 1 hereby tsftffy that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,star laws, and <br /> rules and regulations of the Sen Joaquin Count <br /> Horne Owner or licensed agent's signature certifies tha following: "I certify that in the performance of the work for which this permit is isatrsd, 1 ahes not <br /> employ any person in such manner es to become subject to workman's compensation laws of California. Contractor's hiring or sub-contracting signatues <br /> certifies the fallowing: "I certify that in the parformence of the work for which this permit is issued,I"It employ persona subject to workmen's cow0ensa- <br /> tfon lows of California.,, <br /> The applic st call f" quired inspections. Complete drawing on reverse s � <br /> 4 � Ci <br /> Signed Title:Title: r Data: <br /> l <br /> FOR DEPARTMENT USE ONLY <br /> Appkation Acaspsed by Data At" <br /> Ph or Grout 11`164ee ion by Data Final Inspection by Dow <br /> Addltlortsl Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services 5 �� <br /> Environmental Health Permit/Services <br /> 445 H San Joaquin, P O Bo: 2008, Stkn, CA 95201 <br /> IFEO TED AMOUNT DUE AMOUNT REMITCASH RECEIVED BY DATE PERMWNO, <br /> • fw 13-34 IaEV.ilea) <br /> Eve tt->7 <br />