Laserfiche WebLink
. EM 13-24 IREV. 5 <br />EM 14-211 <br />I! 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 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />Application is hereby made to San 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 No. 549 and 1862 and the Rules and Regulations of San <br />Joaquin County Public Health Services. <br />/ <br />, it**427 City Lot Size/Acreage <br />Address :38// N. 751a)C7 tei2 _Z-1--W72---- <br />Address /W3 /O/Pee#44/04cense No.4k5?;76 Phone <br />TYPE OF WELL/PUMP: NEW WELL 0 <br />PUMP INSTALLATION 0 <br />DISTANCE TO NEAREST: SEPTIC TANK <br /> <br />WELL REPLACEMENT El DESTRUCTIONt of Service Well <br /> <br />SYSTEM REPAIR CI OTHER 0 Monitoring Well <br />SEWER LINES DISPOSAL FLD. --- PROP. LINE <br />AGRICULTURE WELL — OTHER WELL — PITS/SUMPS — <br />0 <br /> <br />FOUNDATION <br /> <br />Job Address 55/ to. <br /> <br />Owner's Name A1/4) 671144#11 <br />Contract 4DY /d2tk) <br />Phone <br />INTENDED USE <br />Ill Industrial <br />[11 Domestic/Private <br />['1 Public <br />I I Irrigation <br />Repair Work Done LJ <br />Well Destruction 0 <br />TYPE OF WELL <br />0 Open Bottom <br />0 Gravel Pack <br />El Other <br />Approx. Depth <br />Type of Pump <br />Well Diameter <br />PROBLEM AREA <br />El Manteca <br />0 Tracy <br />fl Delta <br />XEastern <br />CONSTRUCTION SPECIFICATIONS <br />Die, of Well Excavation S;74v <br />Type of Casing <br />Depth of Grout Seal — <br />Surface Saul Installed by <br />Dia. of Well Casing z•re <br /> <br />Specifications <br /> <br />Aype of Grou <br />VIA*551.W-4-611rzdfirj <br />H.P. <br />Sealing Material & Depth <br />_Siate Work Done ent-t. .Asant — 35 <br />Depth Filler Material & Depth <br />TYPE OF SEPTIC WORK: <br />Installation will serve: Residence <br />Number of living units. <br />NEW INSTALLATION I I <br />Commercial <br />REPAIR/ADDITION I I DESTRUCTION <br />Other <br />I I (No septic system permitted if public sewer is <br />available within 200 feet.) <br />Water table depth <br />Number of bedrooms <br />Character of soil to a depth <br />SEPTIC TANK 0 <br />PKG. TREATMENT PLT. 0 <br />of 3 feet: <br />Type/Mfg Capacity No. Compartments <br />Distance to nearest: Well Foundation <br />Method of Disposal <br />Property Line <br />LEACHING LINE 0 <br />FILTER BED 0 <br />No. & Length of lines Total length/size <br />Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS I I <br />SUMPS LI <br />DISPOSAL PONDS 0 <br />Depth Size <br />Well <br />Number <br />Distance to nearest: Foundation Property Line <br />I hereby certify that I have prepared 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 sub-contracting signature <br />certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br />tion laws of California." <br />The applica required i ctions. Complete drawing on reverse side. <br />Signed X / Title . <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by 44 . A•-'0-12 Date 7-,/2' CI Area t• a • ii-;'' <br />Pit or Grout Inspection by Date Final Inspection by 14AA-c.q Date 2/4/9 if <br />Additional Comments. <br />Applicant - Return all copies to: San Joaquin County Public Health Services <br />Environmental Health Permit/Services <br />445 N San Joaquin, P 0 Box 2009, Stkn, CA 9 <br /> <br />Date. 2- <br /> <br />FEE <br />INFO AMOUNT DUE AMOUNT REMITTED CK Si <br />CASH RECEIVED BY DATE PERMIT NO. <br />/215 Ajte- <br />3 At. tu • cet, <br />3 s.", 2- <br />1--