Laserfiche WebLink
APPLICATION. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> -. <br /> ff ENVIRONMENTAL HEALTH DIVISION <br /> i445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O 13O% 2009, STOCKTON, CA 95201 <br /> lEEii I <br /> T :EXPIRES 1 YEAR FROBii DATE ISSUED <br /> ` (Comp,lete xin:=Triplicate) <br /> Application is hereby made to San$vith San <br /> County qu for a permit to construct and/or install the cork herein described. This <br /> application is made in ootspliance�rrlth San Joaquin County Ordinance No. 51+9 and 182 and the Rules and Regulations of San <br /> Joaquin County Public Health Services <br /> It L <br /> / r^�✓dG 0-V Lot Size/Acreage <br /> ci[v yc.a�—�- <br /> Job Address97 i <br /> Phone aG 1 <br /> R Address yD <br /> Owner's Name _ 7 <br /> Address X06 J✓ -- <br /> License No.� �Phone <br /> Contractor WELL REPLACEMENT ❑ DESTRUCTION C] Out of Service well <br /> fVEW WELL ❑ OTHER ❑ Monitoring well ❑ <br /> TYPE OFWE SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES ���— DISPOSAL FLD. PROP. LINE <br /> Dl57ANCE TO NEAREST: SEPTIC TANK _ OTHER WELL PITSISUMPS i <br /> FOUNDATION �---- AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS pia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. at Well Excavation <br /> Cl Industrial Type of Casing Specifications <br /> ❑ Tracy _ Type of Grout <br /> [} Domestic/Private ❑ Gravel Pack Depth of Grout Seal <br /> 1-1 Other ,i_� Cl Delta <br /> De <br /> p <br /> i"1 Public <br /> 11 Irrigation Appra;: Depth l l Eastern Surface Sol,,, Installed by <br /> 0 Type of Pump <br /> Repair Work Done --- <br /> M P State Work Done - <br /> Sealing Material L Depth <br /> Well Destruction ❑ Well Diameter ---- -- Filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ] fIEPAI1111 TION DESTRUCTION i i availablerwi within 200 feet-1 it public sower is <br /> �! r <br /> Installation willserve: Residence.� Commercial Other <br /> Number of living units: _ Number of bedroom_ s Water table depth O <br /> Character of soil to a depth of 3 feet: G Cepaci[y�___�----�- No, Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT, 0 '� Property Line <br /> Distande to nearest: Well Foundation <br /> I Total length/size <br /> LEACHING LINE No. & Length of lines i <br /> 1 Foundation �D �- _ Property Line - <br /> FILTER BED C] Distance to nearest Wel] -� <br /> �w Number <br /> SEEPAGE PITS )a Depth( Size ` � Property Line�rC! <br /> 1 <br /> SUMPS Ll Distance to nearest: Well Foundation�- <br /> DISPOSAL PONDS ❑ � <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and <br /> i rules and regulations of the San Joaquin County <br /> (1 Home owner or licensed agent's iignature cartifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> of Californiam" <br /> ring <br /> r mp <br /> person nfy coscompensation <br /> Vs a { rbtic <br /> csignature <br /> eertfis the lowing:"Ic that n the performance ofthe wok for which permit is I shall employpersonssubject t workmansompensa <br /> f tion laws of Caiifornla." <br /> i The applicant call for all 'ui(ed inspectio . Complete drawing o reverse -/QIIIII_ <br /> Title: „ �?`�r/�� Date: III <br /> Signed <br /> F DEPA ENT IJ DNLV <br /> Date Ar <br /> Application Accepted by <br /> r Final Inspection by Date <br /> Pit or Grout Inspection by ++ Date <br /> Additional Comments: an Joaquin F <br /> t <br /> County <br /> Public vices. <br /> Applicant - Return all 'copies to: EnvironmentalHealthPermit/Services <br /> k445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> CK RECEIVED BY DATE PERMIT'ND. <br /> FEE AMOUNT'DUE AMOUNT REMITTED CASH <br /> INFO <br /> . EH 17.24 IREV.1/n sr l 43 4/ <br /> I EH 1146 <br />