Laserfiche WebLink
i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I� ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> if P O BOX 2009, STOCKTON, CA 95201 ; <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i (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 /> S O City Lot Size/Acreage <br /> Job Address t � a �] <br /> � <br /> tole) k-00—oun, Phone <br /> w er's Name __ ddress <br /> lc�Y15 ��Q...Y' +fid 1�- �1 <br /> trpM ddress <br /> �,} W License No,`� Phon ~ .� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT�L] DESTRUCTION ❑ Out Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Z�Xr OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \� <br /> Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation , <br /> Type of Casing- <br /> .1. <br /> Cl Domestic/Private Cl Gravel Pack L] Tracy yp <br /> .I �-•-Type of Grout---- <br /> ['1'0 <br /> rout---- <br /> I'I P iblic 9'' ['!'0ih-6 ""r� I1 Delta'^" �— Depth oPGrourSeal - - a <br /> r anon ` �_Approxil�Depth l I Eastern Surface Seal Instahed by <br /> 2 Repair Work Done 'L7 Type of Pump Z H.P. State Work Don <br /> Material & Depth <br /> LE � <br /> Sealing Mate eP <br /> Well Destruction 1❑ Well Diamate�r <br /> f Depth i Filler Material & Depth ` 1 <br /> TYPE OF SEPTIC WQR-K NEW INSTALLATION I i REPAIWADDITION i I DESTRUCTION l I (No septic'system permitted ill-public sewer is <br /> �l available within-200loot.I <br /> t <br /> Installation will serve: iResidence Commercial�_ Other '1 .moi Y¢ <br /> Numbar of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> ' No. Compartments I 'J <br /> SEPTIC TANK. ? � 0 Type/Mfg Capacity P <br /> t PKG.�TREATMENT�PLT..CI Method of Dispfak <br /> i; 1-•6fDistance I�o nearest: Well Foundation Property Line <br />[[[ •` • _^ ` ;.s Total length/size <br /> LEACHING LINE ❑ No.,& Length rxf lines- kf I <br /> FILTER BED [] distan'c'e to nearest: ": well Foundation Property tine _ ^ <br /> F <br /> I� ' <br /> I SEEPAGE PITS t I I Depth ; 3� ! Size Number 4 <br /> SUMPS s u Distance^to.nearest z Well Foundation Property Lina <br /> DISPOSAL PONDS 10 'lig' _ <br /> hereby certify that I have prepared ihes applicai- and that7the..work will be done.in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County iE '' '4> <br /> Homeowner or licensed agent's signature$citifies the follo4wing:-1-certtfy that In the performance of the work tot which this permit is issued, I shall not <br /> .--employ_ttpy person-in such rnanner as to_become.subject to_workman,s compensation laws ol_California."Contractor's hiring or-sub-contracting-signature <br /> certifies the foilowing: "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 applica m t call for �inspe, -ons. Complete drawing on rev a side. <br /> Si ed ` Title: Date: <br /> E II FOR DEPARTMENT USE <br /> ONLY <br /> .1. <br /> Application Accepted by Date_ Area <br /> Pit or Grout Inspection by I� Date Final Inspection by Date 3D 9 <br /> Additional Comments: I" <br /> a Applicant - Return all copies to: San Joaquin County Public Health Services <br /> ,i Environmental Health Permit/Services <br /> I! 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUEL AMOUNT REMITTED �A RECEIVED BY DATE PERMI7'NO. <br /> ` INQFO <br /> . fH 13-24(REV.1/x5Y <br /> EH 14-Za <br />