Laserfiche WebLink
APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ) # <br /> 445 N SAN JOAQUIN, PHONE(209)469-3420 µ <br /> P O BOX 388,STOCKTON,CA 95201-0388 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED3 bad <br /> (Complete in TriplicaLt� ,- -- __.- <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described.This application is made in compliance with San <br /> Joaquin County Development Title Section 9-1130.3 a d Section 9-1115.3 and the Rules and Regulations of Sa Ioaquin County Public Health Services. <br /> Job Address Z City Lot Size/Acreage <br /> r. y <br /> Owner's Name Address � �/ C / Phone Contractor Ss cense NoPJAQ2 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT FI DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTE EPAIR ❑ OTHER ❑ Monitoring Well C3DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONt&out <br /> SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca D' . vation Dia. of Well Casing <br /> ` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type Specifications 4� <br /> I'1 Public fl Other fl Delta Depteal Typa of GroutI I Iniotron _Approx. Depth I I Eastern Surfalled by 9,,I <br /> y, Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material A Depth <br /> Depth _ Filler Material A Depth r� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION fV REPAIR/ADDITION I I DESTRUCTION I I Wo septic system permitted if public sewer is <br /> zavailable within 200 laet.l <br /> Installation will some: Residence _ Commercial Cher <br /> Number of living units: _ Number of bedroom <br /> Character of WO to a depth of 3 feet: A Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity I No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method o�f�D�pi,s�p���,rgyr'1 <br /> Distance to nearest: Wel�Foundetion /� Property Line / \ <br /> r r <br /> LEACHING LINE ❑ No. d Length of lines ,Tge1 length/size Q, <br /> FILTER BED ❑ Distance to nearest: Well Foundation Lr�5,1'v�d/� Propert Line L�1 <br /> ` J <br /> SEEPAGE PITS 11 Depth 4W Size N m er <br /> SUMPS LI Distance to nee At: We Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaq Jin c Ordr �as, state laws, and <br /> rules and regulations of the San Joaquin County a� IlIVV <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work foAfr t fs'l jt issued, I shall not <br /> I <br /> any person in such manner as to become subject to workman's compensation laws of California." Contract�11bin 6 s1S , ntracIing signature <br /> certifies the followin I certi that in tM rformance of the work for which this ermit is issued, 1 shall em to rani n's com nta- <br /> t7: " h M p p y I� TM pa <br /> tion laws of California." - $qN JQAVLII^'t'��IC�.S <br /> The applicant m c}B for al6rednspac ns. Complete drawing on reverse side. PUBLIC 4ALTH 5TH 0 VISIO�� <br /> t. Signed Title: � /�. OCVIRONMENTALHE <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Nor Application Accepted by * Date \ Are <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> bxx Applicant - Return all copies to: San Joaquin County Public HealthServices <br /> ` 1 Environmental Health Permit/Services <br /> v\ 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 4F <br /> Oxx <br /> IEEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> EN 13.24 l aEV.v x er'-"l/�/ i �-n . �U'J / /0n <br />