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 0 BOX 2009, STOCKTON, CA 95201 <br /> . PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application in hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> ' Joaquin County Public Health Services. a/V.:5r1rdP� <br /> � � 7�- �'"dna-3 (0 <br /> Job Address Citi+ � �� Lt Size/Acreage gQ_ o <br /> Owner's Name n Address T a� 1 - / __ Phon � n�39 <br /> O <br /> ' SDE /C45 <br /> A0 -7 5 3 �}- q f, <br /> Conitaclore7C//lril �/ ddress l/19Y�ftj ✓/�- 76-26No P 6rYe� a <br /> - -- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 17 OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES I DISPOSAL FLO.� PROP. LINE`�riv' <br /> FOUNDATION � i 17 r AGRICULTURE WELL OTHER WELL­_11[ <br /> _ l2L PITS/SUMPS _&_ <br /> ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 171 Industrial O Open Bottom ❑ Manteca Dia, of Wali Excavation Dia. of Well Casing a <br /> (:1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casings - iii Specification15151— illi - <br /> ' I'1 Public fq:3�rO�ther n Delta Depth of Grout Seal `v/l�-� _- - - Type of Grout. <br /> I 1 Irrigation I�[J Approx. Depth 1 I Eastern Surface Soul Installed by,1�It l „r,� - - i <br /> Repair Work Done U Type of Pump H.P. S a Work Pone _ <br /> ' Weil Destruction ❑ Weil Diameter <br /> �/ Sealing Material i Depth <br /> Depth 7C) / Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADOITION I I DESTRUCTION 11 (No septic system permitted if public &ewer is <br /> available within 200 feet.) <br /> Installation will Serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms �} <br /> Character of soil to a depth of 3 feel: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line Q <br /> ' LEACHING LINE Cl No. & Length of lines 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: Wail Foundation Property Line <br /> DISPOSAL PONDS 0 <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 iignature certifies the following: "i certify that In the periormancs 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 this work for which this permit is issued, I shall employ persons subject to workman's compensa• <br /> tion laws of California." <br /> The applicant mu t all for all re uirkd inspsctf na. Complete drawing on revs a side. <br /> Signed Title: Date: <br /> LR f}EPARTMENT ON Y <br /> Appflcatlon Aceep d by <br /> V,-0,,W0 <br /> Date Area <br /> ' Pit or Grout Inspection by Date Final Inspection by Date <br /> . Additional Comment$: /D <br /> Applicant - Return all copies to: San Joaquin County Public Health Services �� <br /> ' Bavironmental Health Permit/Services <br /> 14145 N San Joaquin, P O Sox 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> • EH 1]• 00 <OZ7 49V <br /> 24(REV.It sr �fJ�/,� �✓ <br /> ' Ek rt.�e /Jif+ c+r <.+ <br />