Laserfiche WebLink
*APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> A:_ i <br /> i . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> :I (Complete in Triplicate) <br /> Application is hereby made to Sen Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County, Ordinance Ro. S19 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public He. th Services. r. <br /> Ir y I <br /> City , . �> j aLot Size/Acreage <br /> w Job Address <br /> i- - <br /> �r _:_r. _ Phone <br /> Owner's Name i` rA. e Address `"p <br /> � y, License No � k¢ _Phone <br /> Contractor kill; r dress <br /> TYPE OF WELL/PUMP: I�: NEW ELL ❑ WELL REPLACEME T C ..7 DESTRUCTIONVut of Service Well Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L] <br /> OTHER ❑ Monitoring Well <br /> L7 <br /> _ _ -.DISPOSAL-FLO. - PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES :-" <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> .11 <br /> ELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> In Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C7 Industrial ❑�OPe <br /> i; kn <br /> ❑ Tracy Type of Casing— Specifications <br /> r 7 Domestic/Private 01'Gravei Pack <br /> I'] Public d1 Other fl Delta Depth of Grout Seal Type of Grout <br /> V yy . <br /> 11 Irrigation 1?Approx. Depth- I I Eastern Surface Seal Installed by O <br /> w Repair Work Done Type of Pump H.P. <br /> Sealing Material & Depth <br /> St to Work Dona ' <br /> Well Destruction Well Dian eter <br /> U r a } <br /> 1 Depth Filler Material & Depth f1. <br /> l TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I available septic shin system permitted if public sewer is. _ <br /> I <br /> Installation will serve: Rti I�idence_ Commercial___.^ Other <br /> Number of living units: �M Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation <br /> Property Line <br /> r? <br /> LEACHING LINE 01 No. & Length of lines Total length/size <br /> FILTER°BED 0:1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 111'Depth Size Number <br /> !F --`•SUA"MPS LI estance to nearest: Well "Foundation '"�Pioperty Line <br /> DISPOSAL PONDS ❑I[ <br /> { I hereby certify that I have piepared 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 signature certifies 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 workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, Lahall employ persons subject to workman's compensa <br /> tion laws of CelifornI ." <br /> The applica us call for a req d nspections. Complete drawing on{ arse side. <br /> I � €u fi La 4.cu Title: _ Date <br /> p <br /> Signed A <br /> iii _ FOR DEPARTMENT USE ONLY C> <br /> (` ea z 1� <br /> Application Accepted by i , �� Date <br /> r Pit or"Grout Inspection by I�. Date Final inspection b at <br /> Additional Comments:. <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> i Environmental Health Permit/Services <br /> 445 N Sart Joaquin, P O Box 2009, Stkn, CA 95201 <br /> k - FEE AMOUNT DUE AMOUNT REMITTED CK R EIVED By DATE PERMIT NO. [ Q <br /> INFO CASH <br /> . EH 13.21 IR EV.rix 5l Lid <br /> EH 11-20 <br />