Laserfiche WebLink
APPLICATION T <br /> I SR # <br /> SAN JUAtdUIN COUNTY PUBLIC HEALTH <br /> ENVIRONMENTAL HEALTH DIVIS1121bys <br /> 445 N SAN JOAQUIN,. PHONE (209)4 $� <br /> P O BOX 2009, STOCKTON, CA 9 2 t <br /> PERMIT EXPIRES 1 YEAR FROM DATE` IS UED D <br /> (Complete in Triplicate) <br /> Applicationis hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application <br /> is <br /> made in compllance with San Joaquin County Ordinance No. 549 and °1962 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Add <br /> resa ► Cir Lot Size/Acreage <br /> r ' <br /> -7851 RG <br /> Owner's27722 <br /> Name Address hone `3 <br /> ♦` r <br /> Conlracto Lia Address W 7&7 ;License No, 2 2 Z(d Phone (09' "S10 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION O Out of Service well- ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER ❑ Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELL _O_THER WELL d"K E W.F <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Rr <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia.-o e eNsr u <br /> EI Domestic/Private ❑ Graver Pack ❑ Tracy Type of Casing_ S 'a r� <br /> In- <br /> ["I Public Cl Other FI Delta Depth of Grout Seal SATwclE 1( IW \ <br /> I I Irrigation _,Approx. Depth I I Eastern Surface Seal Installed by Ri iSi ic HEALTH SERVICES <br /> Repair Work Done 0 Type of Pump H,P. _ State Work DWVIRONMENTAL HEALTH DIVISIUW— <br /> Well Destruction D Well Diameter Sealing Material i Depth <br /> Depth Filler Material 8 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> � as'I ble with' 2f� feel.?. <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: Number o b Idroom t <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.Cl / f Method of Disposal <br /> Distance to nearest: Well 1_5D_ Foundation_111C •i- Property Line <br /> LEACHING LINE No. & Length of lines Toil length/size <br /> FILTER BED CI Distance to nearest: Well y1601 Foundation ___L_6_ Property Line L� � <br /> SEEPAGE PITSDepth Size .. dumber <br /> SUMPS LI Distance to nearest: Well _ Foundation Property Line �.:Z ` <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, end' <br /> anc <br /> rules and regulations of the Sen Joaquin county � . .J f <br /> Home owner of licensed agent's signature certifies the following: "I certily.that in the performance of the work for which this permit is issued, 1 shall nor <br /> employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or subcontracting signature <br /> certifies the following: "I cenify that in the performance of the work for which this permit is issued, i shall <br /> tion laws of California," employ persona subject to workman's cortipensa- <br /> The applicant call for all aired inspections. Complete drawing on reverse sid0.l <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY - 1 <br /> , Application Accepted by Dale <br /> Area <br /> Pit or Grout inspection by J to Final Inspection by Aare <br /> Additional Comments: ci-vws,+t, <br /> Applicant. - Return all copies to: San Joaquin anty Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE .PERMIT'NO. <br /> /is <br /> t C H <br /> • E>1 13•2I tREV.,i n 5! /vJ (�� i � i �y �n �J(,� <br /> EM 13.74 +El— - f f 3 -�• <br />