Laserfiche WebLink
SAN J f 1 Y -rtJni.lt,�n> i ai va.._ <br /> APPLICATION IT AL HEALTH DIVISION <br /> SAN JOAQUIN COUNTY PHEL I sER`�DUV IT <br /> ISNV I RONI[FNTAL <br /> 1445 N SAN J049UIN, PHONE (209)468-3420 <br /> 1.10 <br /> p 0 BOX 2009, STOCKTON , CA 95201 <br /> ]PERMIT_ EXPIRES 1 Y FR DATE ISS <br /> (Complete in Triplicate) <br /> ode to Flan County for a permit to construct and/or install the work herein described- This <br /> Application is hereby <br /> application is rude in ade.to nce vith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of n <br /> cowli <br /> Joaquin County Public Health services. Lot Size/Acreage <br /> City r <br /> r <br /> Job Address <br /> _.., Phone <br /> g <br /> Address f <br /> Owner's Nome r <br /> License No, � ✓ <br /> Phone <br /> ddtess Out of Service NeIT [t <br /> Contractor WELL REPLACEMENT .r DESTRUCTION <br /> NEW WE OTHER O ltonitoring Well (� <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR Cl I <br /> PUMP INSTALLATION 0�'-`�.,� DISPOSAL FLO, PROP. LINE _ <br /> SEWER,,LINES ---- PITS/SUMPS <br /> DISTANCE TO NEAREST' SEPTIC TANK AGRICULTURE WELL OTHER WELL <br /> FOUNDATION i 6 <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE _.�-- Dia. of Well Casing <br /> O Manteca Die. of Well Excavation r r- <br /> D Industrial O Open Bottom \ Specilications <br /> (-3 Tracy, Type of Casing__— TYf� of Grout l <br /> [I Domestic/Private Cl Delta Depth of Grout Seal�I•Grsvel Pack _ <br /> '1 Public l;l Other <br /> I <br /> �^ ^'.Surface Seal installed by <br /> \`�Approk, Depth I I Eastern <br /> I I Irrtoation .. I + State Work Done <br /> of Pump �--- H.P. t <br /> Repair Work Done U TYPs Sealing th <br /> Material i vep <br /> Well Destruction ❑ Well Diameter <br /> Filler Material pth <br /> Depth fmirted�if_public-s*"*1r is - <br /> TYP£ OF SEPTIC WORK; TtnN-111�'I EPA1R7ADD1TIC5N `DESTRl1CTION I I pNa�able'w ttiirl 200 feet.) - <br /> Other `r---- <br /> Installation will server Residence L—Commercial�. <br /> Number of living units: Numbei of bedrooms - r- _- water table depth <br /> Charactar of SON to sjWth of 3 feet:) 0 _No. Compartments <br /> ❑ Type/Mfg — Capacity <br /> SEPTIC TANK Method o1 Di eROsal <br /> PKG. TREATMENT PLT. Cl ?: O -Property Line (J •<` <br /> pittance to nearest: 1NeH -- FoundatioF ,� J f I <br /> Total length/size x <br /> LEACHING LINE No. 8 Length of Nnet !n Pr It Line �( <br /> Foundation -1 u o� y <br /> FILTER BED O Distance to nearest: Well�, — <br /> $r Size d Number <br /> SEEPAGE PITS I I Depth , - Pr ins d� d <br /> SUMPS Distance to newt: Well � Foundatiq� l L �r/ • �� <br /> i <br /> DISPOSAL PONDS t 0 Svm P 15 IhG4 erv,V r•e1 Oh-�U L2 l3vL ante w `` in( <br /> I hereby cenity that I have prepared this application and that�the wo�rkill b done, n accordance with San Joaq�uirr county ordinance state la <br /> rules and regulations of the Sin Joaquin Coui+ty k 1 �/ all not <br /> Nome owner or licensed agent's signature cenifie -iWolowing:-"I-certify that Xg nature <br /> employ any person in such manner as to become subject to workman'a compehsationlav ' �1jan's corMpansa <br /> ` certifies the folowing: "I unity that in the performance of the work for which SPECIAL PERMIT <br /> tion laws of CaNfornla." <br /> gr , -The applicant must uN for all wired lnspectb s. Complete drawing S' reverse side. T <br /> Title: r Date. f <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> _ Area 2 i <br /> Data <br /> Application Accepted by __- <br /> Pit or Grout Inspection by Date- - - <br /> -• Fins)-Inspection by <br /> � • _ No - <br /> `Additional Comments: 1 <br /> I public Health Services <br /> Pelicanttt RPtu n all co ies San Joaquio County ``\ �j <br /> Environmental health Poroit2009, 5tk <br /> E,tf�?dl 445 N San Joaquin, P O Box 2009, $tkn, CA 95201 <br /> CK RECEIVED BY GATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFQ32- <br /> EK 13-2401EV.s,r bl �'R lk�lp-p <br /> EH tl-1a <br />