Laserfiche WebLink
t <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ra <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE. (209)468-3420 <br /> ° P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EgPIRES 1 YEAR FROM DATE ISSUED ,t <br /> (Complete in Triplicate) <br /> describe <br /> work <br /> in <br /> Application is hperebnmde.to Sanmce Yoahu1inCoo 4 in County Ordinance r a permit to nNoru5k9 and ct o1862eand the tall eRules and eRegulations dof Sans <br /> application <br /> Joaquin County Public Health Service. _ / j <br /> ryc--t � City Got Size/Acreage <br /> Job Address ( I �, <br /> Phone <br /> r Q f��^ Address <br /> Owner's Name � <br /> Address <br /> License N Phone <br /> Contractor WELL REPLACEMENT ll DESTRUGTION Cl Out of Service Well ❑ <br /> TYPE OF WELLIPUMP: NEW WELL ❑ OTHER ❑ Monitoring well L7 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ' <br /> SEWER LINES ���_�-- DISPOSAL FLD. PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK -- AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDATION ' — <br /> INTENDED U5E 3 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Briiiam �❑ Manteca �Dia- of Well Excavation , <br /> industrial ❑ Open ❑ Tracy Type of Casing_ Specifications <br /> C.l <br /> Domestic I Private ❑ Gravel Pack Depth of Grout Seal Type of Grout <br /> M Other ll Delta <br /> 1'4 Public gu e Saal Installed by <br /> 'Repair <br /> ifrioation _ Approx. Dep h I I Eastern r'(7 State Work Done <br /> E Type of Pump �= H.P. <br /> Repair Work Done Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter -- Filler Material & Depth <br /> Depthsystem <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I l aNailable1within 200 leetitjed if public sewer is <br /> t <br /> Installation will serve: Residence Commercial_ Other - <br /> Number of living units: Number of bedrooms Water table depth Y1 <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK (J eTwelMfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line <br /> -Distance to nearest: Well <br /> .1' Total tengthlsize <br /> LEACHING LINE 6 .No. & Length of lines' -` Property Line <br /> FILTER BED n Distance to nearest: Well fountlatii;%;: - <br /> 4' <br /> Sire Number <br /> SEEPAGE PITS I I Depth Foundation) Property Line <br /> SUMPS LI Distance to nearest: Well <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordancIIIe with San-;Joaquin county ordinances, state Paws, an <br /> l not <br /> rules"and regulations of the San Joaquin Countypermit is issued, I work for <br /> this <br /> Home owner or licensed agent's signature certifiesubject thlto workman's kman'srtcoymperisation laws oltCelifornia`he^Contractor srhuing or sub-cont act ng signature <br /> employemploy any parson in such manner as to become <br /> e performance of the work for which--this permit is issued, I shall employ persons subject to workman's compensa <br /> certifies the following: "1 certify that in th - <br /> tion laws of C _` <br /> The apt cant must Date:for all r ins ,tions. Coriiplefe drawing on rave sid <br /> f Title�� Date: <br /> Signed X <br /> FOR DEPARTMENT USE ONLY <br /> Date �- Area <br /> Application Accepted by <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Date <br /> Additional Comments: <br /> t uealthoblic Health ermit/Servicesvices <br /> Applicant - Return all copies to: San Joaquin CountEnv <br /> 445 N San JOa(tui O ox 2009, Sticn, GA 95201 <br /> FEE AMOUNT DUE AM UN7 REMITTED CASH <br /> f CEIVED BY DATE PERMIT NO. <br /> INFO <br /> . EH 13-24 1REV.t 1145) <br /> EH 14.26 <br />