Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
e <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES wt <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOC%TON, CA 95201 �b <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) I <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 rvices. <br /> 71199 <br /> Job Address v ok LLe-r%1 _ City =? C� Lot Size/Acreage <br /> Owner's Nam e�1�e A b Address Phone �� S <br /> I <br /> r ! 9 / �^ o <br /> Contractor .S� ` Rddress [ [ A L --tet to License No. Phone (G <br /> TYPE OF WfELL/PUMP. NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST:-SEPTIC-TANK SEWER.LINES DISPOSAL FLD. ;PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �_ a <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private G4 Gravel Pack 0 Tracy Type of Casing.- Specifications <br /> Il Public is Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation .Approx. Depth l I Eastern SUrface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction O Wall Diamater Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I D STRUCTI N I.l INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_._., Other �� k c �� <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/Mfg Capacity 1204:D No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Welt Foundation Property Line e� <br /> LEACHING LINE No. & Length of lines ---! 3d _ Total length/size 15 <br /> FILTER BED 1=1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I,)5 Depth F2 -Sill y _ X r'D Number <br /> OAC- <br /> SUMPS _- LI,Distance to-nearest: Well- - Foundation - .Property Line .— <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 and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies 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 worknr an'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 compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Compl d wing on reverse side. <br /> Signed X Title: C / I,e-/' Date: Z 23 <br /> 19r-- <br /> FAR DEPARTMENT USE ONLY / <br /> A ication Accepted by Date Area / D(� <br /> Pito Grout Inspection by Date Final Inspection by Data <br /> ditional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 4 Box 2009, Stkn, CA 95201 <br /> # INFO AMOUNT DUE AMOUNT.REMITTED C K H RECEIVED BY DATE PERMIT'NO. <br /> k <br /> +i EH 1J-21(FEV.find s .� PSI �2r.4 �y <br /> EH N-Ze - J ` <br />