Laserfiche WebLink
SAN JOAQUIN COUNTY_PUBLICtH£ALTH-S VLR�.^ �SS- <br /> ENVIRONHENT&T—MALTH DIVISION , <br /> 445 N SAN JOAOIX., PHONE (209)468 34IE2s'tiR <br /> P 0 BOX 2009, STOC%TON, CA 952C1 FAP u <br /> ERNIT S 1 YEAR FROicDAT I UU tt <br /> (Complete in Triplicate) ,1 # i �ip <br /> Application to hereby msde,to San Joaquin County for a permit to construct and/or install the work herein described. s <br /> application is made 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. ,1� ; <br /> Job Address iz e�a E Cit„yL�P •t Size/Acreage <br /> Owner's Nem -//�.�,a� Address ��'r � Phone III <br /> ContrAddress4;4License No. _Phone�7- <br /> ac <br /> J] <br /> TYPE OF WELL Ni NEW WELL 0 �•^ WEL6-REI LACEM NT n DESTRUCTION 0 Out of Service Well Cl <br /> ” / Monitoring Well <br /> f,y PUMP INSTALLATION'S '�.-1 SYSTEM REPAIR-ZY, OTHER O O. - <br /> DISTANCE TO NEARE57: SEPTIC TANK ,/;SEWER CINES ` - DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION `AGRICULTURE WELL " OTHER WELL � s PITS/SUMPS <br /> INTENDED USE ITYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Iu ial 0 Open Bottom O Manteca Dia-of,Well Eaca'vabdn' Dia of Well Casing <br /> omestic/Private'( �. 0 Gravel Pack ❑ Tracy Type of,Casing_ Specifications— <br /> ('I <br /> pecifications I'I Public - 1 CI Other 'n-Detia� Depth of Grout Seal Type of Grout <br /> 1 1 luigation `r 1 Approx. Dept I 1 Eastern ` Starless Seal Installed by er' <br /> Repair Work Done �U I Type of Pump H,P. State r one _ p}+ <br /> Well Destruction O Well Diameter ✓ Sesling Material i Depth i(is'�• <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I:.-REPAIR/ADDITION 1 DESTRUCTION I),INo septic system P01milrdh if puolic sower is M <br /> t / available within 210 feet.l <br /> t ` . <br /> Installation will serve: Residence_ Commercial- Other <br /> Number of living unite: — Number of bedrooms <br /> I <br /> Character of loll tt a depth of 3 feet: Water table depth <br /> SEPTIC TANK. _ • ❑ Type/Mfg Capacity No. Compartments <br /> - PKG. TREATMENT PLT`0 Method of Disposal - <br /> v z <br /> Distance to nearest: Well Foundation Property Line - <br /> (per <br /> LEACHING UNE -,'D No. d Length of lines Total length/sine �L <br /> FILTER BED [--n Distance to nearest: Well Foundation Property Line C <br /> SEEPAGE PITS v. ri I�Depth `- - Size Number " <br /> SUMPS "-�LI-•Distance to naarri —Well -._Foundation Property Lina <br /> ,, _-D.ISPOSAL.PONDS r-�❑ <br /> I hereby certify that I have prepared this apPlication'andiAat iris work will'ba-tlbne-in-accortlance with San-Joaquin.coumy prdinances,_state laws,,antl_ - <br /> rules and regulations of the Sen 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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: 19 certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa <br /> tion laws of Californla..!f 1 <br /> T The applicant mt call,f'or all squir spectlo a. Complete drawing on r ran side <br /> l 1 <br /> Signed Lam/ Title: �. Dow .1 --u���` -�- <br /> ' F DEPARTMENT USE ONLY -- -'� _ •- . <br /> _ n <br /> Application Accepted by Dece VArsn ;L <br /> Pit or Grout Impaction by ,( Date Final Impaction by 4 f— Date Z"/-v"_y. <br /> -Additional Comments: er Sz .T' �� � �" v-0 "tea �`t <br /> Applicant - Return all copies to: San Joaquin County Public Health Services , <br /> T i <br /> t I Environmental Health Permit/ServiceB l) :./ r✓y -/ <br /> '`�• �� t 445 N San Joaquin, P O Box 2009, Stich, CA 95201 I <br /> FEE 'AMOUNT DUE AMOUNT REMITTED C SM RECEIVED BY DATE PERMIT NO. <br /> NFO <br /> • ER ti.nE IREy.Ii•e� �-+ i <br /> 0 <br /> EN tEOa <br /> I <br />