Laserfiche WebLink
tf <br /> SAN JOAQUIN COUNTY PUBLIC n T�ICBS / <br /> 7.9 <br /> ENVIRONMENTAL HEALTH DI I <br /> 445 N SAN JOAQUIN, PHONE (2 420 ` <br /> P O BOX 2009, STOCKTON, oil <br /> P IT EXPIRES 1 YEAR FROM E AM AW&I <br /> (Complete in Tri.plic tI�VV # <br /> Application le hereby made.to Ban Joaquin County for a permit to construct an II - . <br /> application in :wade in compliance with Ban Joaquin County Ordlnance No. 549 and 1662 and the Rules and egu.a one o <br /> Joaquin County Public Health Services. �} <br /> Job Address �.3�� F r _� City r' + rca Lot Size/Acreage <br /> Owner's Name Fe rc a MA.r Q 1i-L Address _ Us h Phone <br /> Contractor iq A r�I n PU M Address eUt Qu !Jq Litense No.-"r'u r S Phone ��7 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT fl DESTRUCTION Cl out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O Monitoring Well C1 <br /> DISTANCE TO NEAREST: SEPTIC TANK 0 SEWER LINES [0)'+ DISPOSAL FLD. PROP. LINE D <br /> FOUNDATION 40 AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS S/ <br /> ❑ Industrial O Open Bottom Lf Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 66�Domestic/Private tib Gravel Pack 0Tracy Type of Casing e Specifications <br /> i'l Public Fl Other n Dena Depth of Grout Seal I a.S Type of Grout <br /> + Irngatron �yApprotr. Depth 11 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump _ K1.P. _ State Work Done <br /> Well Destniction D Weft Diameter Sealing Material i Depth <br /> Depth Filler Material i Pepth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I t INo septic system permitted it public sewer is <br /> available within 200 Joel.Ii <br /> Installation will serve: Residence_ Commercial— Other _ <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 foal: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments � <br /> PKG_ TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well _ Foundation _ Properry LAAV"r�T \ <br /> C `V <br /> 0 <br /> LEACHING LINE Cl No. b Length of lines Total length/si: <br /> UE <br /> FILTER BED ❑ Distance to nearest, Well Foundation - __ Property <br /> _ SAfV J'�Ani Itii P>ti (� <br /> SEEPAGE PITS 11 Depth Sire Nurro <br /> -1C ►irrn �,�1`TTY <br /> SUMPS Ll Distance to nearest: Well Foundation Prnperty <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this atsplicstion and-.that the work will be done in accordance with San Joaquin county ordinances, slate 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 0r which this permit is issued, I shall nor <br /> employ any person in such rnanner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify chat in the pertormance of the work for which this permit is issued, I shall employ parwins subject to workman's compensa- <br /> tion laws of Caiitorn <br /> The applican t Call for all :squired i ctions. Com let awing on reverse side. r <br /> Signeds Title: Date: r —/ED <br /> if <br /> FOR DEPARTM£ USE ONLY <br /> CAIIly <br /> Application Accepted by Date L Ar �7 <br /> Pit oGrout erection by Oate Final Inspection by Gatei_� <br /> Additional Comments: J g;vv _P O - / <br /> Applicant - Retur all copies to: Sao Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> b FEE AMOUNT CUE AMOUNT REMITTED K RECEIVED BY DATE NO. <br /> INFO C <br /> . Er 13-24(REV.rinse <br /> fti 14.N <br />