Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
APPLICATION <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' YEAR FROM DATE ISSUED <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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> K <br /> of) Address 1y ��1 City Lot` 81ze/Acreage <br /> Owner's Name _ e Address �[�J �~� `^ `*',4 Phone <br /> "'r h Address License No. Phone <br /> �ontracto T -- -�-= <br /> TYPE OF WELL/PUMP.- NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Out of Service Well 0 <br /> PUMP INSTALLATION ❑✓� SYSTEM REPAIR,`❑. OTHER ❑ Monitoring Well C1 <br /> DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES �\DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ` � 1OTHER WELL PITS/SUMPS <br /> INTENDED 6SE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j <br /> f_-1 Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private ' ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> 11 Public C1 Other F 1-1 Delta Depth of Grout Seat Type of Grout ' W <br /> I i Irrigation r —Approx. Depth I I Eastern Surface Seel Installed by ~ <br /> Repair Work Done_ LJ Type of Pump <br /> H.P. State Work Done P� <br /> Well Destruction ❑� Well Diameler..' Se&11ni;-Materisl.& Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATI I R�PMR�t ON i I DESTRUCTION I I INo septic system permitted it public sewer is <br /> � _ vailable within 2tb leet.l <br /> Installation will serve: Residence -Co mercrals i <br /> 1REP <br /> Number of living units: Number of bedroomsr� <br /> Character of soil to a depth of 3 feet:r f I I Water table depth <br /> SEPTIC TANK f ❑ Type/Mfg'_ 1 r;Qftlity No. Compartments <br /> PKG. TREATMENT PLT.❑ II,h �i ,�tl �� Method of Disposal <br /> Distance to nearest: i"WeYilran�'%k Lihtla Property Line <br /> t <br /> LEACHING LINE t LNo. Length of lines Total len th/size 1 , <br /> � <br /> FILTER-BED ❑.. -Distance,to nearest: Well Foundation Property Line <br /> I : ' 11 <br /> ',. SEEPAGE PITS I ) Depiti­ Size __ Number f <br /> SUMPS LI Distance to nearest: Well Foundation Property Linew'1 <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 arid regulations of the San Joaquin County <br /> i Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, i shall not <br /> employ any person in such manner as to become subject to workmen'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 compansa- ; <br /> tion laws of California." I v <br /> The applican must call for ail required inspections. Complete drawing on reverse side. y <br /> Signed J24- ._ _ Date: :�2 7 x <br />'r F ARTMENT USE ONLY <br /> Application Accepted by T {l A-Au `Yv. i _�4#J+d _ Date Z�7 r Area <br /> r <br /> Pit or Grout inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> .. t <br /> Applicant - Return*all copies to: San Joaquin County Public Health Services <br /> "�`•w- t~ Environmental Health Permit/Services <br /> P 445..N. San Joaquin, A 0 Box 2009, Stkn, CA 95201 <br /> FEE RAMOUNT D r` AMOUNT REMITTED w CK RECEIVED BY DATE PERNIMNO. <br /> INFO CASH <br /> ■IAS //6A■r�� /� �+�--R7 IT <br /> ff t`P71 r <br /> EH t3-24 4REV,rin 6��,Y VGV FOe tY"^• - e�� ! ` rt [ V <br /> EH 14.2a <br />