Laserfiche WebLink
II <br /> # APPLICATION <br /> W <br /> f <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> i 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> 1 P O BOX 2009, STOCKTON, CA 95201 <br /> a 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 Service4-';t,�it <br /> `. Job Address - Cit Lot Size/Acreage <br /> r f <br /> f t L e �-�T f <br /> Owner's Name � ems.�n� i �� Address?rla r,: L� �� �'a Phon <br /> � 6� <br /> Contractor �' Address License No. Phone <br /> TYPE OF WELL/ UMP: li NEW WELL 13 WELL REPLACEMENT �l DESTRUCTION ❑ Out of Service Well ❑ <br /> �� PUIMP INSTALLATION SYSTEM R R D OTHERW Monitoring We 1 �� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> �rt <br /> i XOomestic/Private Cl Gravel Pack D Tracy Type of Casing_ Specifications ` <br /> !l I'! Public ter �elta Depth of Grout Seal Type of Grout �Q <br /> I I Irrigation p� C pprox. Depth I I Eastern Surface Soul Installed by <br /> I Repair Work Done U Ty jia of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Wel! Diameter <br /> Sealing Material & Depth <br /> Depth Filler Material i Depth <br /> M TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> a <br /> 'I available within 200 feet.) 111 <br /> Installation will serve: Residence— Commercial Other <br /> ! Number of living units: II Number of bedrooms <br /> ' Character of soil to a dsplhlkof 3 feet: -7-A Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ,1 - Method of Disposal <br /> Distance 1. nearest: f1Wel! Foundation Property Line <br /> i� <br /> LEACHING LINE Ll ,No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> IM <br /> SEEPAGE PITS 11 Depth Number <br /> SUMPS Ll Distance to nearest: ell Foundation Property Line <br /> DISPOSAL PONDS ❑ 11. <br /> I hereby certify that I have pripared 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 Sin Joaquin County <br /> Home owner or licensed agent'Is 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 workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the following: "I cortin 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." i <br /> The applicant must call all jliaquitey inspections. Complete drawing on reverse <br /> SignedTitle: Dater Z <br /> I� - <br /> FOR DEPARTMENT USE ONLY e� <br /> Application Accepted by. Date 1 Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> i <br /> I Applicant - Return all copies to: San Joaquin County Public Health Services SIF <br /> Environmental Health .Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMFT'NO. <br /> • EH 13-24(REV.11 n Sl <br /> 11.24 <br />