Laserfiche WebLink
Ap LJ_CATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> }445 N SAN JOAQUIN �2CA)95201420 <br /> P O BOX 2009, STOCgTON <br /> f <br /> 'PERMIT EXPIRES 1-YEAR FROM DATE ISSU <br /> P,L"-- P �Q pc` i (Complete in Triplicate) <br /> Application is hereby made.to Soh Joaquin County for a pe <br /> rmit to construct and/or install the work herein described. This <br /> application is made in compliancvicesh San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin county Public Health BerIR C Lot Size/Acreage <br /> City <br /> Job Address }., - Phone <br /> Address <br /> Owner's Name Phone�� <br /> �.( License <br /> I v Address DES RUC ❑ out of service Well ❑ <br /> Contractor WELL RI PLACEMENT ❑ Monitoring Well ❑ <br /> NEW WELL C] OTHER ❑ (� <br /> TYPE OF WELLIPUMP'• SYSTEM REPAIR nJ\y <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE <br /> `SEWER LINES --- PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER-WELL----- <br /> FOUNDATION �— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> p Open Bottom ❑ Manteca Dia. of Well Excavation <br /> n Industiial � r,ti, . 1,r <br /> Specifications <br /> ❑ Tracy Type of Casing_ Type of Grout <br /> KOomestic/Private C) Gravel k n Delta Depth of Grout Seal <br /> i'1 Public I:� Other <br /> Approx. Depth:. h I_Eastern Sur a Seafi Installed by <br /> H P State Work Oone <br /> Repair Work LDone ] Type of Pmp Sealing Material tr Depth <br /> Weil Destruction ❑ `Well.Diameler ------ Filler Material & Depth <br /> Depth ' <br /> available within 200 Iasi.! <br /> TYPE OF SEPTIC WORK: ,NEW INSTALLATION REPAIRIADDITION ISI DESTRUCTIONr¢}l {moo septic system permitted if public sewer is <br /> / Other <br /> Installation will serve: Residence i Commercial <br /> Number of riving uniis: Num6er-of bedrooms Water table depth <br /> Li <br /> r" F <br /> Character of soil to a depth of 3 teat: Capacity �- • No. Compartments <br /> ❑ Type/Mfg <br /> SEPTIC TANK f � Method of Disposal <br /> PKG.;TREATMfiNT PLT. ❑ � Foundation-���-- Property Line <br /> Distance to nearest: Well O <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line �- <br /> t Foundation <br /> FILTER BED ❑ Distance to nearest: Well <br /> i Number <br /> SEEPAGE PITS 11 Depth Size <br /> l i Foundation `Property Lina <br /> SUMPS LI Distance to nearest: Well <br /> DISPOSAL PONDS Cl 44 <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 Jgoaquin County following: work for <br /> Home owner or licensed agantn^er as to become this permit s i <br /> subjecto workman'srtcomtpensation laws sof California."Contractor'slhiri g or sub-contracting ssulsignlature <br /> f ampioY any person in such ma <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 applic must all for all required in ctions. Complete drawing on rev e• Date: �11 <br /> Title: <br /> Signed 01 <br /> nFOR DEPARTMENT USE ONLY <br /> Date `��_ Area <br /> Application Accepted by /� Data 1 <br /> F r Date�-- Final inspection by <br /> Pit or Grout inspection by <br /> r Additional Comments: <br /> Applicant - Return all;'Copie5 to: Environmentalquin oHealthunty uPermit/Servicesblic Health vices <br /> [ 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95203 <br /> # CKRECEIVED BY D TE PERMIT NO. <br /> fEE AMOUNT DUE AMOUNT REMITTED <br /> INFO (,� <br /> r EH 13-24(REV.v/x 51 1 .Q �! , <br /> 6 EH 11-26 <br />