Laserfiche WebLink
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 EgPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) tlq\ CNI � 14�l <br /> Applis hereby <br /> in compliance with San County <br /> J aquinfor <br /> County Ordinanceconstruct <br /> No. 549and/or <br /> 1862install <br /> and thethe <br /> Rules andeRegulations dof San <br /> s <br /> application <br /> Joaquin county Public Health Services. ri M i <br /> ryy/' City Lot Size/Acreage <br /> /1Job Address f <br /> ddlddl Phone <br /> Address <br /> Owner's Name 3 /f <br /> a License No.3 Phone <br /> Address <br /> LYP <br /> orRUCTION ❑ Out of Service Well I_$TE Of WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ Monitoring Well C] <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ i <br /> SEWER LINES �..�--- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK ��—� PtTS/SUMPS \ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> i� Industrial Ci Specifications— <br /> C:1 <br /> Domestic/Private Gravel Pack Type of Casing— <br /> F1 <br /> Depth of Grout Seal Type of Grout <br /> {'1 Public to Other Cl Delta <br /> I I Irrigation __ Approx. Depth I i Eastern Surface Seal Installed by <br /> H P State Work Done — <br /> Repair Work Done 0 Type of Pump Sealing Material & Depth <br /> Well Destruction El Well Diameter Biller Material 8 Depth <br /> Depth <br /> TYPE OF SEPTIC WO <br /> RK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION Ivo septi cyst em 2t�feetit`ed if public sewer is <br /> . Other --- <br /> installation will serve: Residence____ Commercial—.y <br /> Q Number of living units: Number of bedrooms <br /> I Water cable depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK 0 Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well foundation P Y <br /> Total length/size <br /> LEACHING LINE Cl Na. & Length of tines ' Property Line <br /> FILTER BED C) Distance to nearest: Well Foundation <br /> Yry Number <br /> SEEPAGE PITS I Size! Depth property Line <br /> SUMPS Ll Distance to nearest: Well Foundation <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, stale laws, and <br /> rules and regulations of the San Joaquin County o <br /> ature certifies the to "I certify that in the performance of the work for which this permit is issued, !shall n <br /> Home owner or Licensed agent's signt <br /> such manner n to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ any person in ss <br /> certifies the following: certify that 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 /> T e applicant must call for all requir inspections. Co plate drawing an reverse side. <br /> igned <br /> T/ Title: Date: <br /> 1 DEP TMENT USE ONLY <br /> Date � �' 'L.� Area <br /> Application Accepted by <br /> Date <br /> Pit <br /> Pit or Grout Inspection by Date final Inspection by <br /> Additional Comments: <br /> Applicant - Return ail 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 /> FEEAMOIiNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> 1 <br /> . EH 13-24IREV.�rKe�.S\J d . <br /> EH 11.1E <br />