Laserfiche WebLink
APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ygivyX0 <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 APR 29 <br /> 1993 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ENVIRONMENTALH <br /> Application In hereby made to San Joaquin County for a permit to construct and/or install the work herpeiri'rgTOf-i WCE s <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 '__ T//'/ /�a-rr �- <br /> _, _-___ Ciw Lot Size/Acreage <br /> Owner's Name Ll-ur A Address <br /> Contracto Address �+<f icense No. PhoAetl'���� <br /> TYPE OF ELL/PUMP, NEW WELL Cl WELL REPLACEMENT D DESTRUCTION Ll Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well U <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> FI Domestic/Private ❑ Gravel Packs n Tracy Type of Casing_ Specifications <br /> I'I Public I-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> l I Irrigation _Approx. Depth l I Eastern Surface Soul Installed by <br /> Repair Work Done LJ Type of Pump H.P. . State Work Done _ ^� <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth 0 <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDiTION DESTRUCTION l I INo septic system permitted if public sewer is <br /> available within 200 feet.) t 2- <br /> Installation will serve: Residence-Y-.. Commercial_ Other <br /> Number of living units. -I— Number;'�.,b-e�-�d�ro��orr-m--sem-� VW Character of soil to a depth of 3 feet: a ebbe d <br /> SEPTIC TANKZII$r­`❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1&60d-e4—k__ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINEAXW, ' 1 N . S ength of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: abort Property Line <br /> SEEPAGE PITS�, AA� 11 Depth Si e l Number <br /> � <br /> SUMPS /V ~v A Distance to nearest: Property Line <br /> DISPOSAL PONDS ❑ <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 shell 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 applicant must 211 for all require in".cti ns. Complete rowing on reverse side. J� <br /> Signed s ' 4 Title: __1 _ Date: <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by wA+`M / ��� at Date Area _C - ■ �`�` <br /> Pit or Grout Inspection by Date Final Inspection by pats <br /> Additional Comments: ~ XAJ- f-2 <br /> Applicant - Return all copies to: San ukuin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH Cy RECEIVED BY DATE PERMIT'NO. <br /> EH 13-24 EH1�161REV.rin51 •L9 [ <br />