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 13 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ <br />(Complete in Triplicate) <br />Application is hereby made to San Joaquin County for a permit :o construct and/or install the work herein described. This <br />application is 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. <br />Job Address 1--i ^ -1 [ tlYl4 CI- ilC v �C� 11 :.ot 5ize/Acreage '� �LGC�rc <br />Owner s Name EX I.N �G-n,IJc'rnc i l 5� Address �3GC=-�ct�r�� \'��� rt fL5 c% Phone kfC �Zu/l�'S �L <br />Contractor <br />TYPE OF W'ELL/PUMP. <br />DISTANCE TO NEAREST <br />NTENDED USE <br />Industrial <br />Domestic/ Private <br />'7 Public <br />,�adress V6.. & X vulBc�,(4 Fg90 _ cense No. e—" bZ.(.:`(�, P�Ionei-ZC'11195'2`1 <br />NEW WELL Z YELL REPLACEMENT 7 DESTRUCTION �7 Out of Service Well <br />PUMP INSTALLATION C SYSTEM REPAIR Z. OTHER Monitoring Well _- <br />SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP _INE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Open Bottom a Manteca Dia. of Well Excavation Dia. of Well Casing <br />C Gravel Pack _7 Tracy Type of Casing_ Specifications <br />1.1 Other i -I Delta Depth of Grout Seal Type of Grout CC 111c � `t F'„ iI c <br />Irnpation — Aoorox. Depth I Eastern Surface Seat Installed by <br />Repair Work Done _7 Type of Pump , P ___ State Work Done _ <br />Well Destruction Well Diameter Sealing Mater:ai b Depth <br />Depth Filler Materia'_ L Depth <br />TYPE OF SEPTIC WORK. NEW iNSTALLATION REPAIR: ADDITION DESTRUCTION iNo septic system permitted it puoiic sower Is <br />avauaote within 200 feet.) <br />Installation will serve: Residence _ Commercial . <br />Number of living units: Number of bedrooms <br />Character of soli to a depth of 3 feet: <br />SEPTIC TANK C 'me/Mfg <br />PKG. TREATMENT PLT. C <br />C.stance to nearest: Well <br />LEACHING LINE C] No. 6 Length of lines <br />FILTER BED ❑ C:stance to nearest: Well <br />„;tier <br />_aoacity <br />=ounaation _ <br />Foundation _ <br />Water table depth <br />No. Compartments <br />Method of Disposal <br />Property Line <br />Total lengtn/ size_ <br />Property Line <br />SEEPAGE PITS I I Depth Size Number <br />SUMPS LI Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS Cl <br />I hereov certify that I have prepared this application and that 1110 work will be acne in accordance witn San Joacium 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 parrnit Is issued, I shall not <br />employ env person In such manner as to become subject to workmen s compensation laws of California. ' Contractor's hiring or suo-contracting signature <br />canif Ns the foltowing: "I certify that In the performance of the work for which this permit is issued. I shall employ persons suolect to workman's compensa- <br />tion laws of California." <br />The applicant must call for all required Inspections. Complete drawing on reverse side. / <br />I �l <br />Signed X Title: -�zc�` ��C c'�%�, tS Dots: 2 <br />l FOR DEPARTMENT USE ONLY <br />Application Accepted by "-" '- ( Date / r Area <br />Pit or Grout Inspection by '� "�"Date/ FInal Inspection by 7� `"'� / Date <br />Additional Comments: <br />Applicant - Return all copies to: Sjn Joaquin County Public Health Services <br />Environmental Health Permit/Services <br />445 H San Joaquin, P O Box 2009, Stkn, CA 95201 <br />FEE AMOUNT DUE AMOUNT REMITTEDH ,ASRECEIVED By I DA <br />!NFO <br />f.do 0 6 Nom- <br />PERMIT NO. I ' <br />1 Page 13.4 <br />