Laserfiche WebLink
,± APPLICATION FOR PERMIT <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 /> u IT E%PI ES 1 Y3AA FRpll DAA <br /> (Complete in Triplicate) <br /> in <br /> Application is hereby made.to San Joaquin county <br /> uinoCounte OrditnancenNo�5L9ct anand <br /> oi�e�theeRules andeRegulationadof San <br /> s <br /> application is Made in Compliance with San Joao y <br /> Joaquin County Public Health secl+ ; / <br /> Lot size/AcreageCity <br /> Job Address <br /> J Phone <br /> Address <br /> Owner's Name 2 <br /> l� a if 1� Y�3��y� Pho 7 <br /> Contractor <br /> Address L ce se tfo.�-- <br /> el <br /> TYPE OF WELLIPUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out Monitor ng Yell O <br /> _ PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES � DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK �» <br /> FOUNDATION, ——)AGRICULTURE WELL, p1T5/SUMPS OTHER WELL , <br /> INTENDED USE TYPE OF WELL f PROBLEM AREA CONSTRUCTION SPECIFICATIONS • Dia. of Well Casing <br /> ❑ Industnal O Open Bottom A ❑.Manteca Dia. of Well E><cavation Specifications <br /> Cl Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing_ <br /> (�Other —_n h o <br /> Delta Deptf Grout Seat Type Of Grout <br /> I'I Public `. <br /> I I Irriylation _,Approx. Oapth--r I I Eastern Surface SeLd installed by <br /> H.P. State Work Done_ <br /> Repair Work Dore U Type of u g ing.Naierial i Depth <br /> Well Destruction ❑ Well�lameter Tiller VL erisl'.i•.Depth <br /> DepthJ " ' <br /> TYPE 0f SEPTIC WORK, NEW INSTALLATION I l REPAIR/ADDITION DESTRU9L-LOYN;I I ayeila Septicle 01 M Irani{d 1f public sewer +s OJ; <br /> Commercial Other <br /> Installation wNl serve: Residence r Y• <br /> Nun-bet of living units: Number of bedrooms _ , <br /> �'' Water tants depth <br /> Cha�rscter of soil to a depth of 3 feet; - -- <br /> SEPTIC TANK 0 •Type/Mfg Capacity_ No. Compartments <br /> PKfi TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: i Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size . <br /> FILTER BED O piatanSi to newest: Weil _, Foundation Property Line <br /> l i f SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Oisunce-to l rest: We11 d FouFou�rtdstion�- Property Line �� - - <br /> ~ DISPOSAL PONDS ❑ �� f /tkLZ <br /> I hereby unity that I have prepared this a_ppReatici and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> ruts,and r29L a,iona of the San Joaquin County <br /> Horne owner or licensed agent's signature oertif'+es 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 workmen's compensation laws of California."Contracio Qanr ring subject t -contman1acompature <br /> certifies the folowirp:"i certify that in tits performance of the work for which this permit is isswd,1 shall employ Pe w <br /> tiongsws of Calltornts. <br /> <" TheappGN ftx �°dfi; ctmte drawing on reverse side. <br /> „/ b`T/ ! Date: <br /> Tltts: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> A ica))tlon Accepptted_bey <br /> Date / Area or f5rorut�nspotion byate JJ �Final inspection by ai;L2 <br /> I--,' � <br /> Additlonal Commalts: <br /> Applicant - Return all copies to: Sam Joaquin County Public Health Services 3 <br /> Environmental Health Permit/services' <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> E I PEE K RECEIVED 0Y DA PERMIT NO. <br /> f IN 0 AMOUNT 0t1E < AMOUNT REMITTEt? <br /> j, <br /> r <br /> • EH 13:1 IAEV.1 i R,) / <br /> EH 14-30 ' " <br />