Laserfiche WebLink
- APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMMTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P 0 Bog 2009, STOCKTON, CA 95201 <br /> PERI[ T MIRES 1 YE FROId D T U <br /> (Complete in Triplicate) <br /> Thi <br /> plication is hereby made to San Joaquin County for Count Ordinancemit to <br /> construct9 and or install <br /> i2 and tthe <br /> Rules work hand erein described. Sana <br /> A} liance with San Joaquin Y <br /> application is made in coup <br /> Joaquin County Public Health Services. ; t' <br /> i�-v <br /> 2 Z Lot Size/Acreage � <br /> -SIL- City , <br /> Job Address 7Z - Z <br /> Address <br /> . Qwner�s,Name <br /> 1 X % -. .". .- 3-11177-10 Phone (c `S JO S <br /> AddressPr) ii� License No.3) <br /> � Con'Eraclo ' DESTRUCTION ❑ put of Service veli ❑ <br /> NEW WELL ❑ WELL REPLACEMENT n Monitoring Well p <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR 0 OTHER ❑ <br /> PUMP INSTALLATION ❑ � . <br /> DISPOSAL_FLO, POOP. LINE <br /> SEWER LINES �----� . _ .. -.. .� - <br /> DISTANCE TO NEAREST:_SEPTIC TANKS .. �-r- PITS/SUMPS}. <br /> -' FOUNDATION �._� AGRICULTURE WELL OTHER WELL <br /> I <br /> I ON SPECIFICATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIDia. of Well Casing _. <br /> ❑ Open Bottom 0 Manteca Dia. of Weil Excavation: <br /> C7 Industrial *,Type of Geeing- �nc <br /> Sol <br /> [I Domestic/Private ❑ Gravel Pack C] Tracy p y pi t N <br /> fa Other Cl Delta Depth of Grout Seal # <br /> i'l Public • p"-'" <br /> ' i I Irrigation — Approx. Depth 1 I Eastern Surface 5eui Instalwd by <br /> TV"of - f State Wow Done <br /> Repair Work Done L] Tyof Pump Sealing 1laterisl`i"Drpth <br /> Web Destruction ❑ Well Diameter <br /> � Muer Material i Depth <br /> Depth r <br /> 4 ar is <br /> f TYPE OF SEPTIC WORKAIRlA <br /> 11 11 : NEW INSTALLATION REPDDITIO fr. DESTRUCTION, ati r �� <br /> t <br /> Installation will serve. Residence Commercial Other <br /> Number a1 living units: Number of rooms .„.- _.,T- -:.}A ” <br /> --: ,-~ Water table depth <br /> Character of soli to a depth of 3 feet: �• r No. Compartments <br /> SEPTIC TANK. >Eg(- Type/Mfg <br /> gy Method of Disposal. <br /> } PKG. TREATMENT PLT.❑ <br /> ` <br /> WellO 't =�.. <br /> Property Line <br /> ne -- <br /> i Distance to merest <br /> ,�� F.oundatlon <br /> LEACHING LINE No. fie Length of lines Total length/size. , !t <br /> 0 Distance to nearest: Weil�f Foundation Property Line — <br /> FILTER BED <br /> Silo Number <br /> SEEPAGE PITS it Depth-- <br /> f)i+stance to nsanst:� <br /> Well `Foundation�I�r� FPraperty Line --- <br /> t. <br /> DISPOSAL PONDS ❑ i_ *+ <br /> I hereby certify that I have prepared this application and that.the work will be done in accordance—---an, <br /> rules and regulations of the San Joaquin County ' ' Voequin county ordinances, state laws. and <br /> I 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, l shall not <br /> employ any person in such manner as to become subject to workman's laws of California." Contractor's hiring or sub-contracting signature <br /> r certifies the following:"I certify that in the performance of the forwrhich thispermit is issued, I shell employ persons subject to workman's companss <br /> tion laws of California." y <br /> The applican st ull for side <br /> uir inspeetions. Complete drawing on reverse <br /> Signed X <br /> A <br /> `Tiilac� f — Date <br /> FOR DEPARTMENT USE ONLY i0 <br /> j <br /> Data Area <br /> Application Accepted by <br /> Date Final lnapection by Data <br /> Pit or Grout Inspection by <br /> Additional Comments: / • ~ <br /> 1 <br /> Applicant - Return all copies to: San Joaquin County Public th Services <br /> Environmental Health Permit/services <br /> I 445 N San Joaquin, O Box 2009, Stkn, CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT 011E AMOUNT REMITTED <br /> . EH 13-24(REV.11 a 6) <br /> SP— <br /> r EH 14.26 <br />