Laserfiche WebLink
rvurrun nuv nun w� .. c.� <br /> INTENDED USE —TYPE OF WELL PROBLEM AREA CONSTRICTION SPECIFICATIONS <br /> nInd stria) .� Open Bottom ❑ Manteca Dia, m ..ell Excavation Dia. of Well C <br /> omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 0 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CI Ir(igation .Approx,pDepth Eastern ,� Surface Seal Installed by <br /> Repair Work Done Type of Pum H,P. State Work Done " <br /> _ Well Destruction O Welt Diameter Sealing Material L Depth Pl✓1. +Y./�� <br /> Depth Filler Material a Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION CI INo septic system permitted it <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: _ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth_ <br /> SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments <br /> PKG. TREATMENT PLL ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. g Length of lines Total length/sire <br /> FILTER BED ID Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS If Depth Size Number <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 ordinal <br /> rules and regulations of the Sen Joaquin County <br /> Home owner or licensed agent's signature certifies the following's "I certify that in the performance of the work for which this permv <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub- <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 w <br /> tion laws of California." <br /> The applicant mus [r all required ins coons. Complete drawing on revyyy���a side. <br /> Signed X Title: ; �� - Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 4yic4(_e Date ll �Z Area _ <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOR 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOVNT nEMITTED RECEIVED By DATE PERMI <br /> INFO AMOU '/UNT a, / AT p <br /> . CH13241REV. yin l� Z��• o-� Y'�` ��V /t/T�(�— <br /> EM tb2a <br />