Laserfiche WebLink
,.,144 �, I <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 E%PIRES,l YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) in <br /> work <br /> Application is hereby ��ce withuBenC,oToaquinty for <br /> County Ordinancemit to nNo. 549struct 8and o1862sand thtall e Rules and Regulations dof San <br /> s <br /> application in <br /> Joaquin County Public Health Services. /] <br /> s,0, Cr Gj r. Ja ��iry <br /> Lot size/Acreage TTGa7c + <br /> ,/Job Address i t x `� f �J <br /> 14031604 Address �� �` ` Phone <br /> V Owner's Name A3 } - <br /> Contractor Address ` r <br /> LiCense No. 0q Phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION X 0+it of Service Well <br /> TYPE OF WELLlPUMP: OTHER C3Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES �.�— DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION ______�-- AGRICULTURE WELL OT <br /> kER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA" CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> L0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation, <br /> Type of Casing_ Specifications <br /> [.l Domestic/Private ❑ Gravel Pack C] Tracy Depth of Grout Seal Type of Grout <br /> I' Public I1 Oiher n Delta <br /> I Surface Soul Installed by <br /> Irrigation f( ..Apprax, Depth t I Eastern <br /> H.P. <br /> State Work Done <br /> Repair Work Done U Type of Pump t �` <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth Js <br /> Filler Material S Depth <br /> Depth <br /> t TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION availablerc system wi within 200 feetl�ed it public Sewer is <br /> l <br /> --^ 4 <br /> installation will serve; Residence— Commercial Other — <br /> Number of living units: ' Number of bedrooms Water table depth — <br /> .Character of soil to a depth of 3 feet: <br /> Capacity— No. Compartments <br /> SEPTIC TANK 0 Type/Mfg Method of Disposal <br /> I PKG. TREATMENT PLT. L7 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size Ch <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line 5k <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> i L <br /> DISPOSAL PONDS ❑ <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 CountyI ' <br /> i ollowing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the f <br /> r employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature�- <br /> certifies the following: 111 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 applic t e I for all required inspections. Complete drawing an reverse side./ g,�, <br /> a/Signed <br /> Title: if?1� , "`�"'•9k -- Date: <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by - <br /> ©a- I <br /> i <br /> Date Final inspection by Date <br /> Pit or Grout Inspection by - <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 O Box 2009, Stkn, CA 95201 <br /> ► FEECK RECEIVED BY DATE PERMIT'N0. <br /> INFO S=TT <br /> CASH1757 <br /> W() [-a� 3 <br /> EH 13-24'IREV,i/K51 i <br /> EH 14,20 # <br />