Laserfiche WebLink
.0 <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />.ENVIRONMENTAL HEALTH DIVISION <br />P O BOX 2049,,STOCSTON, CA 95201 <br />( 209) 468-3447 <br />PERMIT EAPIRES 1 YEAR 9R -OX RATE ISSiIEQ <br />(Complete in Triplicate) <br />Application is hereby made to San Joaquin County fora permit to•oonstruct and/or install the work herein described. This <br />application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of $en <br />Joaquin County 1Public Health /Services. � <br />Jab Address ) [ UC`t; r'ir� r / 0g_1 t6.t�i'ALot Size/Acreage l J�w'f7ila� <br />Owner's Name Address ! ` !=�IA"I �-i Phone <br />Contractor AddresS, +''k2 V' :__1- .1'Y% �� License No.�- ^ F'horte��L1 f I0 <br />TYPE OF WELL/PUMP: NEW WELC3W WELL R£PL`ACEMENT-n- --'-DESTRUCTION-C-l-Out-of Siitvice-Heli--o1 <br />PUMP INSTALtAT10Isfa SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br />DISTANCE TO NEAREST: •SEPTIC TANK• f.C?Q `7"_ SEWER LINES 1- -"' D I S P O S AL. F L D. �`7` �. PROP. LINE ���✓� <br />FOUNDATION AGRICULTURE WELL —e--" OTHER WELL SPITS/S.U.MPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS <br />�.. <br />('1 Industrial pen Bottom ❑Manteca Dia, of Well Excavation ' Dia. of Well Casing d 5A <br />Domestic/Private-.,.. F_-]-Gravel-Pack r� Tracy �_ _ , _Mede -of Casing ,_,-•Specificatiogs..._... <br />M Public I"I Other Q Delta Depth of Grout Seali% pe of Grout TV <br />�f <br />Q IrriUation Approx. Depth fl Eastern Surface Seal installed by AdMA <br />Repair Work Done L) Type of Pum _ H,P. r _V i. <br />ork-Done <br />Well Destruction D W meter Sealing lteteria <br />Depth _ _ Filler ial�pth'�- -� --- - ' <br />TYPE OF SEPTIC WORK: NEW INSTALLATION f) REPAIRIADDITION 'f DESTRUCTION El (No septic system permitted it public sewer is <br />available within 200 feet,) I <br />4 i <br />Installation will tserve: Residence Commercial — Other, <br />Number of living unite: — Number of bedrooms <br />Ch <br />. `r .f- <br />aracter of soli to a depth of 3 feet- / �° Water table depth <br />SEPTIC.TANK ❑ Type/Mfg ; Capacity t^ r* ..-•! No. Compartrionts r <br />PKG. TREATMENT PLT, " :=a.,. ,!- Method of Disposal <br />{ 0; <' . <br />Distance to nearest: alt > k Foundation r_ ' _ .Property Line, i <br />LEACHING LINE a .._. " <br />GIL:_No. & Lang I jines �`"^ ' Tota). lengfti/siie� TMs' <br />FILTER BED Cl Dit:iinc o uerr5st: Well _ . Foundation �y Property Line- _ - ; <br />SEEPAGE PITS I i epih ,_,_Sim _ _ Number <br />SUMPS Distance to nearest'. _ Well Foundation _____,_, Property Line <br />]ISPOSAL PONDS ❑ <br />rwfouy.cernry mat I neve prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br />rules and t*gulations of the San Joaquin County <br />Homo 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 shall not <br />empioy any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring at sub -contracting signature <br />certifies the following: "I Certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa• <br />tion iaws of Celifornl " <br />The applicant rnus a�f_WLreauirpd jpspectyna , f; imp eta drawina on reverse side. r .. <br />/ <br />MFOEPARTMENT USE ONLYApplication Accepted by "_ Date Area 2— t <br />ro Inspection by F� i�r alert - Final Inspection by = �,�,� Data <br />Pit or f <br />/ <br />Additional Comments: _ <br />Applicant - Return all coplers to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION iPERMIT/SERVICES " <br />445 N SAN JOAQUIN. P 0 IIOX 2009, STOCKTON, CA 95201 <br />H 13-2/ 9W. l t n 5, <br />H 114,20 <br />EEE <br />C <br />INFO <br />AMOUNT <br />NT DUE <br />AMOUNT REMITTED <br />CASH <br />t1ECEIVED BY <br />DATE / <br />PERO.M17 N <br />n <br />