Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE .(209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> pERMIT EXPIRES 1 Y kR FROM DTE ISSUIM <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 coMllance with San Joaquin.County Ordinance No. 549 and 1862 and the Rules and Regulttlans of San <br /> Joaquin County Public Health Services. <br /> L V'v elpff&l City P;'A VrjLc& Lot Size/Acreage <br /> .fob Address <br /> Phone <br /> Owner's Name G�4 n Address <br /> r Address �p0-v �Lv 4401-1 License No. <br /> W1 Phone <br /> Contractor DESTRUCTION ❑ tit of Service Well ❑ <br /> TYPE OF WAO�L�ELL ❑ WELL REPLACEMENT n Monitoring Well ❑ <br /> - PUMP INSTALLATION ❑ SYSTEM REPAIR 11 OTHER C3 ` <br /> f 1SEWER LINES ��-- DISPOSAL FLD. PROP. LINE <br /> DISTANCE 70 NEAREST: SEPTIC TANK <br /> FOUNDATION AGRICULTURE WELL OTHER,WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR08LER .AREA=f CONSTRUCTION-SPECIFICATIONS <br /> Dia. of Welt Casing <br /> ❑ Industrial [I Open Bottom 0 Manteca Dia. of Well Excavation Dia. of <br /> C.1 Domestic/Private C1 Gravel Pack 0 Tracy Type of Casing_. <br /> f 1'Defta Depth of Grout Seal Type of Grout <br /> I'1 Public rl Other ` � <br /> I I Irrigation Approx. Depth t I I Eastern)— —Surface-Seal-Installed by --- <br /> tt H.P. State Work Done — <br /> Repair Work Done L] Type of Pump f sealing Material & Depth ` <br /> Well Destruction ❑ Well Diameter 0— , I r,�^ <br /> liner Material i Depth <br /> Depth _ <br /> TYPE AF SEPTIC WORK; NEW INSTALLATION REPAIRIADDITION i I ED) TRUCTION I I availableNo iwitin system permitted <br /> tted it public sewer is <br /> 2 <br /> f'�fBbiL. H014C � <br /> installation wf l serve: Residence Commercial Other ; <br /> -Number of bedrooms <br /> Number of living units: .�..� Water table depth 146.0 <br /> Character of soil to a depth of 3 feet: 0,vd <br /> 1 _@.r-.q s+T _ -Capacity I �4 0- - --- No. Compartments <br /> j SEPTIC TANK $1 Type/Mfg - _;LO <br /> Method of Disposal <br /> 1 PKG. TREATMENT PLT.❑ <br /> r Distance to hsarest: Well ±O_aA Foundation iO Property Line <br /> LEACHING LINE gr No. 6 Length of lines <br /> Totat length/size ' r <br /> O-f- >�f <br /> FILTER BED ❑ Distance to nearest: .1 <br /> Welt .--- <br /> Foundation Property Line <br /> F ` <br /> � £ � J \ <br /> j SEEPAGE PITS 11 Depth Size Number <br /> SUMPS IN Distance to nearest: Well �a Foundation O __ Property Lined <br /> I 1' <br /> DISPOSAL PONDS ❑ <br /> ` I hereby certify that! have prepared this applicatiowand that the work will.be.done in accordance.with-San Joaq 'county ordinances, state laws, and <br /> r <br /> rules and regulations of the San Joaquin County <br /> Home owner o►licensed agent's eignaturs certifies the following: "1 certify that in the performance oft work f ,which this permit is issued, 1 shall not <br /> employ any person in such manner as to become wbject to workman's compensation laws of California! Con[ra toi s hiring or subcontracting signature <br /> eanifws the following: "I certify that in the performance of the work for which this permit is issued,k shall employ persons subject to workman's compensa <br /> tion laws of California." ; <br /> The applicant must call for ell required inspections. Complete drawing on reverse side. 3 <br /> Signed _ <br /> Title: Date: <br /> QRARTM USE ONLY <br /> Date Are a� — <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date _. Final Inspection by Date 3 <br /> Additional Comments: <br /> Applicant - Return all copiies to: San Joaquin CodntyyPublic Health Services <br /> Environmental°Health.Permit/Bervices _ <br /> t 445 N San Joaquin, p 0 Box 2009, Stkn, CA 95201 <br /> - "�` _.- FE AMOUNT DUITT <br /> E { AMOUNTREMED ; CA \ RECEIVED By_ ATE PERMIT'NO. <br /> IN <br /> 1 % <br /> . Er113-24(Rev.1/95 <br /> EM 14.25 <br />