Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
, <br /> •. ` APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTAt <br /> ENV I RONI[ENTAL HEALTH D I V I 0 <br /> N 445 N SAN JOAQUIN, PHONE (2090 <br /> P 0 BOX 2009, STOCKTON, CA 9520\\0 I ,,1 .. <br /> PERMIT EXPIRES 1 YEAR FROM DATE I UID <br /> (Complete in Triplicat¢ +�5 <br /> Application is hereby made to San Joaquin County for a permit to construct and install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address <br /> D3 a'tf� City Lot Size/Acreage 'sr�^AEZ�,— <br /> Owner's Name $ ftt— i t=—L-1 Address mit+ Phone <br /> Contractor�� i lei ���Address License No.q_'30,fa�Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> FI Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_ Specifications <br /> I'1 Public El Other F I Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _._ Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. -- State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 4--REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Res r nce commercial_ Other <br /> Number of living units: Number of bedrooms 3 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Cn � f E�Z,- Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method <br /> 2of�Disposal <br /> Distance to nearest: Well Foundation_� Property Line _ <br /> LEACHING LINE L4----ko. & Length of lines a ta�lsngth/size <br /> FILTER BED ❑ Distance to nearest: Well._42ar Foundation Property Line <br /> SEEPAGE PITS ILL�pth Size Number _C�_ <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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 <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> 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: "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 applican mu II for all r ired ' spe. I ns. late drawing on verse side _ <br /> Signe Title: Date: <br /> FOR DEPARTMENT USE ONLY q <br /> Application Accepted by Date AP a9a ` <br /> Pit or Grout Inspection by Date Final Inspection b Date%�L�y <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 /> FEE/� l) INFO AMOUNT DUE AMOUNT REMITTED `CASH RECEIVED BY DATE PERMIT'NO. <br /> . <br /> EH13'24 IREV. n sl jI-aQf�'�1/ �r` �� 0,0l�L <br /> EH 1426 <br />