Laserfiche WebLink
t APPLICATION FOR PERMIT <br /> EIVED <br /> SrliN JOAQUIN OCTAL,HEALTH DIVISION <br /> C ETALTH VICES �� <br /> ENVIR J�1 L 2 5 #9Q <br /> 1601 E. HAZELTON AVE. , PHONE CA 95201 4 <br /> P O BOX 2009, STOCKTON' CA 95201 ENVIRONMENTAL AL HEAI_.TH <br /> I� <br /> Egp RES 1 YEAR FROM DA E PERMIT/SERVICES <br /> (Complete in Triplicate <br /> rmit to constructand/or <br /> install. <br /> and thethe <br /> Rules andvork eAegu7ationsde <br /> dof Saisn <br /> Application is hereby made•to San'.3oaquin County549tY Ordinance tlo• 4 9 <br /> andl$62 <br /> in camp <br /> application is made San ,Foa45 <br /> Joaquin County Public Health Services. Lot Size/Acreage <br /> City r �� <br /> Job Address f phone <br /> 7 ( /,/ ddress / <br /> Owner's NamePhone / <br /> / f License N <br /> ddress pEgTRUCTION ❑ put of Service Well ❑ <br /> E C n ac or�_ WELL REPLA MEN7 ❑ Monitoring Well 0 <br /> NEW WELL ❑ OTHER ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ <br /> Ii PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE <br /> ------ <br /> SEWER LINES J-------- - <br /> -- PITSISUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK _---�— AGRICULTURE WELL OTHER WELL ------- <br /> FOUNDATION �---- <br /> INTENDED USE TYPE OF WELL PROSL.J. EM AREA \CONSTRUCTION SPECIFICATIONS pia of Well Casing <br /> ❑ Open Bottom <br /> ❑ Manteca Dia. of WeII Excavation Specifications- - <br /> Cl Industriak 3 =- - of-Casing=-- �� <br /> [1 Gravel Pack-T-- - �jfaI y-1 �,. Type of Grout <br /> tic/Private -- n Delta D Pth of Grout Seal, <br /> I'I Public t:1 Other mace Seal �s�tied by f <br /> Approx� E stern i , ! ork Done <br /> ` I I tmoation �r P�(,r H P <br /> 1 Repair Work Done>< Type of Pu `f/ �aling;yfaterial,& Depth <br /> Well Diameter --- W-1-&r <br /> Well Destruction ❑ ,Filler MA tei <br /> r� Depthr <br /> + b I Depth _ tic system permitted if public sewer is <br /> ! available within 200 feet.) <br /> TYPE OF SEPTIC WOR N _INSTAI CATION l 1 REPAIR IAODITIO l }DESTRUCTS l { p <br /> Commercial Other. — t <br /> Installation will serve: Residence _ ; t <br /> Number.of living units: <br /> Number of bedrooms Water table depth <br /> i Character of soil to a depth of 3 feel: p&pagily '"�""-- -a•�No. Compartments <br /> I SEPTIC TANK 0 Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ I -+.�.. Property Line <br /> % '± Distance to nearest: Well Foundation �^�-- <br /> � - ,.1 '�7otal_fengthlsiz'e <br /> LEACHINGLINE 0 No. &ILength of lines Property Line — <br /> FILTER BED j C) Distance to nearest: Well �--- <br /> Foundation <br /> r Number I <br /> SEEPAGE PITS 11 Depth Size Property Line <br /> Foundation <br /> SUMPS Cl Distance to nearest: Well Jv. v-- <br /> i_ _ DISPOSAL PONDS <br /> 0.1— ` —t. '- �-• _ r 4 r <br /> 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 /> I hereby <br /> rules and regulations of the San Jogaquin County g „ <br /> Home owner or licensed agent's si na`uore certifies <br /> s the folio w+orkman'srtcompensation lawn of California." Contractowork for rs s+hiring+or sub cont act ng sign not <br /> employ any person in such manner as persons subject to workman's compens <br /> j certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ <br /> I <br /> tion laws of California." <br /> The Wst <br /> call for I required insP4ctions. Complete drawing on r rse s' Date: <br /> T <br /> Sign <br /> I FOR EPARTMENT USE ONLY <br /> Date Ar a <br /> G Application Accepted by ZZ g <br /> + Date --- Final Inspection by <br /> Date <br /> Pit or Grout Inspection by <br /> � r <br /> Additional Comments: joaqt <br /> Applicant ` Return all Copies to: S 1 u1Eavi onmentalCounty iHealthtPermit/ServiceStocktons CA 95201 <br /> i 1601 E. Hazelton Ave., P 0 Bax 2009, <br /> CK RECEIVED BY BATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> E <br /> . EH 13-24 tREV.i/n S+ <br /> EH ti•2E <br />