Laserfiche WebLink
i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> .ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ��` <br /> PERMIT EXPIRES I Y FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to.San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in ocitpliance with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address ��/ 7 P, rl!�,> Z-4un el, - -- CityW .,� t Size/Acreage _ <br /> Owner's Name i � Address 4', I.?.�Q�ir� L---/' <br /> Phone <br /> � ?1� License No Phone <br /> Contractor Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 <br /> 'rDISTAIVC'E'TO MEANEST-SEPTlC"Ti4NK'T 'T" SEWER-LINES—­ -DISPOSAL FL-D.�—T—PRPP-LINE^--- -�. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications <br /> i'l Public EI Other .HCl Delta _ �. Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I Eastern "" Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Naterial i Depth t� <br /> Depth Filler Naterial A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIRlADDITION i I DESTRUCTION 1 I, (No.septic system permitted if public sewer is v <br /> �-L 'available within 200 feet.) \\ <br /> Installation.will serve: Residence commercial— Other <br /> Number of living units: —I— Number of bedrooms 1. _ <br /> Character of soil to a depth of 3 feat: d a tr _._Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg L Capacity l4,9610 No. Compartments <br /> PKG. TREATMENT PLT.❑ �� �1 Method of Disposal 4 <br /> Distance to nearest: Well��*Foundation [ls�� Property Line- - <br /> Q <br /> LEACHING LINE No_d Length of,lines �- �� Total length/size. / <br /> FILTER BED ❑ Distance to nearest: Well��rr Foundation GC? Property Line 165E?ff <br /> SEEPAGE PITS p1h 99S10e7_ _Sire +3�� r� _- Number <br /> ` SUMPS 0 Distance to nearest: Well-_A�_ ��­Foundalion "' _ d�-Property Line X442 i=V7— <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in sccordance wiih'­San'Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin-County <br /> „ Home owner or licensed agent'■signature certifies the following: "I certify that in the performahcs of the work for which this permit is issued, 1 shell not <br /> employ any parson in such manner as to become subjs0'to workman's compensation laws of California.” Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall sm 'I persons subject to workman's compensa- <br /> tion laws of California." a , <br /> The applicant must call far 1 mqtirpd inspections.`Complete drawing on reverse side. ' <br /> /./ ! <br /> Signed KTitle: "'� "Dater <br /> M <br /> FOR DEPARTMENT USE ONLY <br /> I t, Axw 4 <br /> ^'4 q„-• 9 <br /> Application Accepted by Date A Area <br /> Pit Grout Inspection by Date`~ ~^Final Inspection by Date 2 <br /> Additional Comments: -- <br /> Applicant - Return.all copies to: San Joaquin County Public Health Services <br /> # Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 - ?^ <br /> -FFE AMOUNT 6tJE AMOUNT REMITTED CK RECEIVED flY." DATE PERM17 NO. <br /> INFO CASH <br /> . EmM24(REV: is YLVL r <br /> ffi 14.10 <br />_` <br />