Laserfiche WebLink
! )A <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES _ <br /> ENVIRONMENTAL HEALTH DIVISION Y <br /> 445 N SAN JOAQUIN, PHONE (209)468-3 0--- <br /> P <br /> _P O BOX 2009, STOCKTON, CA 95201 SIR # <br /> PERMIT RES I YEAR FROM E S D # 1 <br /> (Complete in Triplicate) <br /> Application 1► hereby oade.to San Joaquin County for a permit to construct and/or ins FACjA tl& n do Fc <br /> application is made in casplianee vith Sap Joaquin County 0 dinance No, 5L nd 1862 the Rules and egu�sti of Ban <br /> Joaquin County Public Health Service%. <br /> INV# <br /> 1 <br /> ♦' <br /> Job Address City <br /> • 1 <br /> Owner's Name _ Address Phone <br /> Contractor Addr ss • 0 Na, one <br /> TYPE 0 WELL PUMP: N WELL ❑ WELL REPLACEIb ENT 1 i DESTRUCTION t of Service WellCl <br /> PUMP INSTALLATION G SYSTEM REPAIR G OTHER G Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELt. PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial U Open Bottom D Manteca Dia. of Well Excavation_ Dia. of Well Casing <br /> Cl Domestic/Private 0 Gravel Pea 0 Tracy Type of Cas+ng_ _ Specifications <br /> I'I Pt tw, Cl Olher fl Delta Depth of Grout Seal _ Type of Grou <br /> I a.MF.patan ____Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done Ll Syps of Pump H.P. _ State ork <br /> Well Destruction k—Y/Welt Diameter Scaling Material a 13rpth <br /> Depth Pill.r Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/AOD!TION I ! DESTRUCTION l I (No septic system permitted if public sewer is <br /> , available within 200 feet.f <br /> Installation vWI serve: Residence_ Commercial_ Other <br /> Number of living units, Number o1 bedrooms _ <br /> Chsrotter of soil to a depth of 3 feet. Wear table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG:TREATMENT PLT.0 Method of Di1111 r <br /> Distance to nearest: Wel _ Foundation Property Line r A C <br /> RECEIVED ina�l <br /> LEACHING LINE C1 No. b Length of lines Total length/size JUN 2 9 OR <br /> FILTER BED CI Distance to nearest: Well Foundation _ Property Line <br /> SAN JOAQUIN COUNTY <br /> SEEPAGE PITS I 1 Depth _Sire Number FQSL(�;Ht.AL I tl Si:KV(GtS O <br /> LTH DIVISION <br /> SUMPS LI Distance to nausst: Well Foundation Praparly Lrne <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this aprpillication and that the work will be done in accordance wish San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin �,oanty <br /> Home owner or licensed agent's eign atwo certifies the following: "I certify that in the performance of the work for which this permit is issaed, I shell not <br /> employ any person in such manner as:o become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signstwe <br /> certifies the following: "I cenify that in the ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws Of Calif <br /> The=.."Im c for al fiquired t- a. Cpmpleto drawing ra rse aide <br /> Signed Title: Date. ._ <br /> R DEPARTMENT USE ONLY <br /> Application Acceptee by Date t+' Area <br /> Ph w Grout Inspsctlon by ata Final Inspection byAM Date 6_30 <br /> -44 <br /> Additional Comments: AXh ZAJC'9rMYr & <br /> Applicant - Return all copies to: San Joaquin County Public Health Sirvices <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95 01 C O/� <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY OA J LJ <br /> m Amo I �-M/41 3 1 <br />