Laserfiche WebLink
APPLICATION <br /> SAN: AQUIN COUNTY PUBLIC HEALTH VICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ;w 445 N SAN �TOAQUIN, 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 /> Application is hereby c=Wlo San wiitthuSanCJ County <br /> ie County Ordinancermit to nstruct No. 549aando1862stall and the Rules andwork ein Regulationsof Sans i <br /> appllcatlea is rile 1 e>t! <br /> Joaquin County Public Health Services. c <br /> C City.L-Z/J �. _ Lot Size/Acreage -- <br /> Job Address fig U <br /> OM 1Phone <br /> Owner's Name Address <br /> Contractor s <br /> z License IVcI,�� � Phone <br /> Addres <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION 0. 'i. SYSTEM REPAIR L OTHER O <br /> Monitoring Well <br /> Ir DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ci Industrial ❑ Open Bottom © Manteca It. Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Cl Gravel Pack 0 Tracy 3 Type of Casing Specifications <br /> I'1 Public n Other f1 Delta Depth.of Grout Seat Type of Grout <br /> I I Irrigation _Approx. Depth I i Eastern ii Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H P. State Work Done — ~ <br /> Wall Destruction ❑ Welt Diameter Sealing Material Ik Depth cZIO <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITIONA DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.1 <br /> Installation will serve: Residence ICv Commercial_ Other <br />'i Number of living units: _J_ Number of bedrooms <br /> Character of soil to a depth of 3 feet:_sADCFU�E— —Water table depth <br /> SEPTIC TANK.4-41_41— 0 Type/Mfg Capacity-� No. Compartments <br /> PKG. TREATMENT PLT. 0 r Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines _ eJGe2 Total length/size 4&2! <br /> a FILTER BED ❑ Distance to nearest: Well&2�* Foundation-/-;g— <br /> Property Line t!S'! <br /> SEEPAGE PITS f I Depth , -��1� Sire �f Number�JE— S� <br /> SUMPS ]x( Distance to nearest: Well � Foundation "JF- 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 performance of the work for which this permit is issued, 1 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 /> certifiis 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 spplicanLmust call for all required,49s ctions. Complete drawing on reverse side. <br /> SignedTitle: -�L r _ . Data: <br /> OR DEPARTMENT USE ONLY <br /> Appli ion Ajccc '" by -4 ' _ ps i Date - � l� Area •V� <br /> or Grout rns coon by j�f---J Date Final Inspection by <br /> Additional Comments: <br /> �z <br /> f Applicant - Return all copies to: San Joaquin County Public Health Services a r <br /> Environmental Health Permit/Services <br /> i' 445 N San Joaquin, P 4 Box 2009, Stkn, CA 95201 <br /> r tFEEO AMOUNT DUE AMOUNT.�RnEMITTED C K RECEIVED BY DATE PERMIT'NO. <br /> • EH 17.24(REV, i n 37 `� - V / 9 <br /> ll t7 r i <br /> EH 1140 w r- <br /> .I�y _ <br />