Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEsS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN__JOAQUIN, PHONE (209)468 -3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Sao Joaquin County for a permit to construct.and/or install the work herein described. This <br /> application is made in ccepliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sin <br /> Joaquin County Public Health Services. <br /> I <br /> Jab.Address 63711.. E . J a h a n t c4c_a In D O Lot Size/Acreage 32 <br /> Owner.'s-Name A n g_elin_Pjla1 l Address Phone - 262 <br /> Contractor Clark Well Address 2024 E _ Chari-pr _ _—License No. 3Z1_fit]___ Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Xq Out of Service Weil ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR Gl OTHER ❑ Monitoring Well C7 <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 gt_j_ ' PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> * Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> * Domeslie/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications <br /> I"1 Public 1:1 Other n Delta -Depth of Grout Seal Type of Grout <br /> i <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter I?"_ ding Material i Depth Ek ft -35 s <br /> � <br /> _ Depth Filler Material & Depth W Inj <br /> TYPE­0F_-SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 2W feet.) <br /> installation will serve: Residence_ Commercial_ Other .- <br /> Number of living units: Number of bedrooms y <br /> Character of will to a depth of 3 feet: Water table depth m <br /> SEPTIC TANK. 0 Type/Mfg Capacity-. No. CorMpartment= <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. Iii Length of lines v Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Lina i <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shad not <br /> employ any person in such manner as to became subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature I <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shad employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applies u cal for �Ieqelns ctio . Complete drawing on reverse side. <br /> Signed Tide: VP Clark WPI ] Date. - 1 3 Ap r� <br /> /__ ___ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 15 Date /51 Area ! / <br /> Pit or Grout Inspection by Date Final Inspection by ✓ Dots <br /> r <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services G/ <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE+ AMOUNT DUE AMOUNT REMITTED <br /> INFO CB �RE�CEIVED BY � DATE PER^�MITr-N <br /> O. <br /> EN 13-24(REV.i ll s! nO © <br /> F6rFH 11•IB <br /> 3 I <br />