Laserfiche WebLink
4 <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> \, ENVIRONMENTAL HEALTH DIVISION <br /> k 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> t P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joe uin Count for a <br /> q y permitty construct 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-San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> Owner's Name 444 I Wit+' _- Address Phone <br /> . t <br /> I Contractor f ; Address 1�. .- 6 i tas-&4 License No.&0961V Phone -) <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT:(7 DESTRUCTION L1 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR❑ OTHER ❑ Monitoring;Well <br /> f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSIS, .MP,S <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Cising <br /> ❑ Domestic/Private O'Gravel Pack 0 Tracy Type of Casing_ Specifications- <br /> I'] Public Ci Other Fl Delta' `Depth of Grout Seal j <br /> � - ype of Grout, <br /> 11 Irrigation % r —..Approx. Depth l I Eastem Surface Seal Installed by <br /> Repair Work Do,4— Type of Pump H:P. State Work Done _ w <br /> Well Destruction ❑"";Well Diameter Sealing Material,& Depth <br /> Depth Filler Material 6,Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION I I (No -if-publicseptic system permitted sewer is <br /> available within 200 feet.) t <br /> Installation will serve: Residence Commercial_ Other' <br /> Number of living unite: Number of bedr6oms <br /> Character of soil to a depth of 3 feet: _Water table depth <br /> SEPTIC TANK ❑ Type/Mfg _„_.. �} _,-__ +`-!'c?�rfcfl-ea�Capacity '— N "Companments 1� <br /> PKG. TREATMENT PLT. C1 f Method of Disposal <br /> Distance'.to nearest: Well Foundation <br /> Property Line <br /> I TEACHING LINE P,--No &`Length of lines <br /> To;al length/size <br /> FILTER 'BEDn Distahice,:to nearest: Weil Foundation <br /> -- . Property Line 0 r <br /> SEEPAGE PITS I I ..Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line i <br /> �•' DISPOSAL PONDS ❑ + F <br /> I 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 shall not <br /> employ any person in such'manner'as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature <br /> certifies the followings,.,'ll 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 laws of California. <br /> The applicant must-611 for alh're"uire <br /> -` d inspections. Complete drawing on reverse side. <br /> ` 1. <br /> Signed X it%/Title: P <br /> .zv+r��.:> Date: <br /> F DEP TMEN SE ONLY <br /> Application Accepted by Date a <br /> Pit or taut Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> 'Applicaht'-=�RetGrn all'c-opies'" o:”Sait'JoaQuin County Public Health Services —f— <br /> Environmental. Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Sthn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVES BY DATE' PERM17'NO. f "� <br /> yINFO <br /> f <br /> EH 132 iREV. s�. <br /> EH 14.20 , V: <br /> - - 5 <br />