Laserfiche WebLink
APPLICATION FOR PRRr'd4V - <br /> SAN JOAQUIN COUNTY PUBLIC HEA - V <br /> ENVIRONMENTAL HEALTH DIVI IONI <br /> 445 N SAN JOAQIIIN, PHONE (209) 68'—"3 <br /> P 0 BOX 2009, STOCKTON, CA <br /> 2EMIT EXPIRES X YFdkg FRQ1M q�aS 3 <br /> (Complete in Triplicat <br /> F e <br /> Application is hereby msde,to San Joaquin County for a-perralt to construct and/or install the work herein described. This <br /> application is made in coregsllance with Elan Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Se cea. 1 <br /> Job Address f /t <br /> City Lot Size/Acreage <br /> Owner's Name,74& G 2 Addresse Phone <br /> v- 49�r <br /> Contractor U Address d License No.1�3 ZI Z 0_Phone vAir <br /> t TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well C] <br /> is PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK" SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> f <br /> INTENDED-USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial s ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestie/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> I1 Public n Other fl 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 lb Well Diameter Sealing Material i Depth <br /> Depth Filler Naterial i Depth <br /> TYPE OF SEPTIC WORK: NEW.INSTALLATIQN REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> ` available within 200 feat.) <br /> FF Installation-will serve: Residence_ Commercial_ Other re[E <br /> 4 Number,of,living units: Number of bedrooms )` <br /> Character,of soil to a depth of 9 fest: Water table depth i <br /> SEPTIC TANK. _ ❑ Type/Mfg /�• Capa ity No. Compartments U <br /> PKG. TREATMENT PLY.-❑ �t�.SG�Q1t37G0 Method of Disposal <br /> i <br /> Distance to nearest: <br /> Wall":k0 Foundation Property Line <br /> I LEACHING.LINE Cl No. 6 Length of lines �44 Total length/size <br /> FILTER BEO ❑ Distance � • 'O•� <br /> to nearest: Well .Foundation Property Line <br /> SEEPAGE PITS I I Depth '� ~� Size__�� d �/ Number t <br /> SUMPS Ll Distance to nearest: Well&M Foundation Property Line N <br /> � �. <br /> DISPOSAL PONDS ❑ <br /> I'hereby certify that I Have prepared this application and that the work will be' done in accordance with San.foaquin county ordinances, state laws, and <br /> " rules and rpulationa 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 em to <br /> tion Ism of California." P Y persons subject to workman's eompsnsa- <br /> Ths epplica st cfor regained inspections. Com rowing on erse side. <br /> Signed f <br /> Title: �Z� _ Data: <br /> i FOR DEPARTMENT USE ONLY <br /> Application Aceepted by 00 Data Area <br /> Pi <br /> Pit-orYsTwrInspection by -- Data 141 Final Inspection Date <br /> IK�14 <br /> ' <br /> # Additional Comments. ♦f <br /> Applicant Return all copies to: San Joaquin County Public Health Service <br /> ; rrjY <br /> '144_e,017 445EnviNpSan eJoaquin, P 0 Boxtal Health 2009, Stkn, CA 95201 <br /> gIce TQ d.i►��re .�'w�rr ��rr <br /> t Ise t�•ffi FEE AMO/U�HT O�1E jAM,OU`Nl/T,RE�MIT\TED � R/E/CyE�IVE�D BY DATE/�g pP2E6RMr/0I1'rfN0p.NFO CA <br /> F11]24tIlEY.ss ] JS q {�✓,` <br /> O�+ <br /> V <br />