Laserfiche WebLink
APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 6 <br /> Application'"Ss hereby made to San oaquln County for a permit to construct and/or install the work herein described. This <br /> application is made in cocipliance with San Joaquin County Ordinance No. 549 and 1802 and the Rules and Regulations of San <br /> - Joaquin County Public Health Services. Q <br /> Job AddressT�/ t (- l7l'/�' (U� L C�tv — / Lot Size/Acreage 997-,0 <br /> /�"y��? /� �j <br /> Owner's Name rC7 ( Address' ��� L��;�_, Phone `��.3 �/ <br /> Contractor r ' <br /> address -✓ �/= License No. �� (fir Phone <br /> TYPE OF WE*/'PUMP NEW WELL C WELL REPItACEIVIENT 71 DESTRUCTION C Out of Service Well Ll <br /> PUMP INSTALLATION--� SYSTEM REPAIR ❑ OTHERMcnitoring Well,C] <br /> DISTANCE TO NEAREST: SEPTIC TANK Ste= SEWER LINES 4, DISPOSAL FLD 6th PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION' (( <br /> 17 Industrial ❑ Open Bottom C Manteca Dia, of Well Excavation ' Dia. of Well Casing C <br /> N Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> r.. I'l Public 1-1 Other f7 Delta Depth of Grout Seal T/ype of Grout <br /> I I Irrigation —Approx. Depth Eastern Surface Seal Installed by r <br /> Repair Work Done U Type of Pump H.P. __. State Work Done _ <br /> Well Destruction ❑ Well Diameter Suing Material L Depth <br /> Depth Filler Material i Depth IZZ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIRIADDITION t I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: Um f R$' e'• <br /> r <br /> Character of soil to a depth o )er Water table depth_ <br /> SEPTIC TANK O T /Mfg , �C�p�city No. Compartments <br /> PKG. TREATMENT PLT. ❑ t��ffT11 1Y}jj1� NIV0 ;���r@ ,trntl '+UUnll Method of Disposal <br /> Distance ` e to t i!?awsw06� Prcperty Line C <br /> ii�E G u„ <br /> f�n <br /> ,ry Lill.iJ <br /> LEACHING LINE O No. b gihWM= 11 d Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <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, 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 peiformance 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 C ' rnis." <br /> The applicant call f all requir in t' n Coaact <br /> ing on reverse side. L,L <br /> Signed > _ le: > Date: <br /> FOR EP TMENT USE ONLY ^/ <br /> . Z.�„ Date —� Area <br /> Application Accepted by <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 /> FEEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DAT PERMIT NO. <br /> INF/Ol <br /> -- EM 13-24 <br /> 111Y. /14v v <br /> 1- d 1� " <br /> T/ <br />