Laserfiche WebLink
APPLICATION <br /> Lel �� � ' � •�} .. y-,-_ `• '� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE . (209)468--3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUID <br /> ,y (Complete-d, Triplicate) I <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the herein described. This <br /> Rules <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San �I <br /> Joaquin County Public Health Services. ' S'�C TG At Lot Size/Acreage Ha <br /> City J , <br /> Job Address <br /> Phone <br />'F [ Address / porr <br /> Owner's Name PRS Phone i <br /> S S ddress D t-GA License No. <br /> Contractor WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ <br /> Vll <br /> MS•�f,' TYPE OF WELLlPUMP. <br /> -NEW WELL C7 OTHER p Monitoring Well <br /> CWOfTl(* :2.44.REdiut 4&PUMP INSTALLATION dff•3010fif t VAtf"EM REPAIR DISPOSAL FLD. PROP, LINE <br /> SEWER LINES ---�--- P1T,5lSUMpS <br /> _ DISTANCE TO NEAREST: SEPTIC TANK —j AGRICULTd1RE,WELL�IL=— ?HER�VsIELL. —_- 'F ! <br /> COANW.FOUNDATION �-`±L,—r F , <br /> WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> TYPE OF W `\ <br /> INTENDED USE �---- Dia. of Well Casing !ti' <br /> Bottom ❑ Manteca Dia.;of Well Excavation <br /> , ❑ Open Industrial ❑ Tracy Type of Casing_ <br /> Specifications— <br /> [:] Domestic/Private ❑ Gravel Pack Depth of Grout Seal Type of Grout <br /> I-1 Other f 1 pelta <br /> -iia-Public ` Surface Seal Installed by <br /> �Ifngation Approx. Depth 4 I Eastern Slate Work Done — <br /> of Pump - H.P. <br /> Repair Work Done U Type Sealing Materiel & Depth <br /> Well'Destruction ❑ Well Diameter �'� <br /> Filler Material b Depth � <br /> Depth <br /> y TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRIADDITION I f DESTAUC710N I I aNailab etrwithin e200 feetrt}ed it public sewer is { <br /> L <br /> Installation will serve: Residence Commercial s_ Other----� �r <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity--- No. Compartments <br /> SEPTIC TANK D Type/Mfg Method of Disposal <br /> I PKG. TREATMENT PLT. .) Foundation Property Line -- <br /> Distance to nearest: Well rn <br /> Total length/size 1 <br /> k LEACHING LINE ❑ No. & Length of linea Well Foundation Property Line�-- <br /> FILTER SED ❑ Distance to nearest: �. <br /> tSire Number <br /> SEEPAGE PITS 11 Depth Property Line <br /> SUMPS Ll Distance to nearest: Well Foundation— - Yµ <br /> —DISPOSAU 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 g work for <br /> Home owner orslicensed agent's <br /> m is siger n torheeome s the folio wrorkman's�compensauon laewsoof Califopn she Contractor's othis p sub-conermit is lt act nglsignatushall re <br /> employ a Pe <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 laws of California." ' <br /> The applicant must call for all r - d inspections. Complete drawing on reverse side. <br /> Title: Date: <br /> Signed x <br /> FOR DEPARTMENT USE ONLY <br /> Area <br /> Date <br /> k Application Accepted by <br /> ed Final Inspection by Dat <br /> Pit or Grou�nspection by Date� — r <br /> ft r �� �.a•r�z <br /> Additional Cor rnitts*, <br /> 1 Applicant -Kte�u n all topica to: a oaqui County Pu c ealth ery ces <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O-Box2008; "Stkn, GA 95201' /! <br /> CK RECEIVED BY DATE PEAM1T'NO. <br /> ZCOE <br /> MOUNM!; <br /> T REMITTED CASH. <br /> t <br /> • EH 13-26 IREV.4eiw5110 <br /> EM t4•2a $ <br />