Laserfiche WebLink
I <br /> APPLICATION <br /> f 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 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for o�pe nNoru51+9uct and/or <br /> 1862install <br /> and thethe <br /> Rulwork es <br /> and eRegulations of San <br /> in described. s <br /> application is made in compliance with San Joaquin county ordinance <br /> Joaquin County Public Health Services. <br /> 5® Q 5Q �' at SCity �4Lot Size/Acreage <br /> fst 00 ofljctt?ihf y <br /> Job Address �H <br /> AddressIf i <br /> Phone <br /> owner's�Neame p ti �5 6q to 6 <br /> 045 F �04��'n' � ddress PMAOX " 3 v ���4`I License Nv. - have <br /> Contractor <br /> DESTRUCTION ❑ Out of service well <br /> TYPE OF WELL/PUMP: NEW WELL ❑. WELL REPLACEMENT �l <br /> THER p Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPA�R ❑ / <br /> SEWER LINES- _4__eJ DISPOSAL FLD.— PROP. LINE LE <br /> DISTANCE TO NEAREST: SEPTIC 7ANIC a� AGRICULTURE WELL V OTHER WELL 450/ PITS/SUMPS itIA <br /> FOUNDATION <br /> �y J/ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing C <br /> n industrial ❑ Open Bottom d Manteca Dia. of Well Excavation Specifications Z — <br /> Type of Casing— <br /> fl <br /> asing_ G <br /> f l Dom ❑ Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout <br /> 1.4 Public S:1 Other f 1 Delta <br /> ,I I Irrigation !:W Approx. Depth l I Eastern Surface Seal Installed by <br /> of Pump H.P. ---- State Work Done _ <br /> Repair Work Done [� Type sealing Material & Depth/B+ ` <br /> Well Destruction ❑ Well Diameter' Filler Material 5 Depth*A`0'0nc_Ake � <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION] l I DESTRUCTION I I eNatl�perwulhin 200 feetystem .) if public sewer is <br />} <br /> Installation will serve: Residence�� Commercial _ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet:, No, Compartments <br /> SEPTIC TANK ❑ Type/Mfg 1 Capacity <br /> 4� Method of Disposal <br /> 0PKG. TREATMENT PLT. Property Line-f�c1F�l1�ENT <br /> Distance to nearest: Well Foundation <br /> Total length/size <br /> LEACHING LINE ❑ No. 8 Length of lines <br /> 1993 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line �— <br /> i <br /> SEEPAGE PITS 11 Depth Size Number ICES <br /> SUMPS Ll Distance to nearest: Well Foundation Pro[1W"INAENTAIL HEALTH DIVISION <br /> DISPOSAL PONDS ❑ t <br /> i H be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that l have prepared this application and that the work wi <br /> I rules and regulations of the San Joaquin Countynot work for hs <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the perlormaa of hContractor ich t i spermit is issuenglsignlll "" <br /> employ any person in such manner as to become subject to workman's compensation laws o California." <br /> 5 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 /> !1 The applicant mus,_ ( for�rulqednspections. Complete drawing on reverse side. {A <br /> Signed <br /> Title: f Date: 1 <br /> 3 FOR DEPARTMENT USE ONLY 1 � <br /> Date <br /> Application Accepted by Date <br /> Pit <br /> Date ` Final Inspection by <br /> i <br /> Pit or Grout Inspection by r T `lG 7 <br /> Additional Comments: } rJ $ <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P U Box 2009, Stkn, CA 95201 Of6Qgr ®�!w <br /> CK RECEIVED By 'PATE PERMIT'NO. <br /> FEE ��rD <br /> AMOUNT DUE AMOUNT.REMITTED CASH <br /> INFO <br /> . EM 1324{RI:Y.1/"si � �.� <br /> EH 14.16 ZZ <br />