Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES '1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby Ieade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is Stade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and,Regulations of San <br /> >. Joaquin County Public HealthiServices. _ <br /> City Lot Size/Acreage <br /> Job Address I[ <br /> Owner's Name <br /> _ Address �� r Phone <br /> / ( —L-icerrse-No:- - =Phone-� -22 <br /> ctor� _ — �-'Address- 2 J • <br /> 7 E OF WELL/PU _I N NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP�WSTALLATION 13 SY TEM REPAIR <br /> OTHER ❑ Monitoring Well I.7 i <br /> DISPOSAL FLO. PROP. LINE <br /> DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINE5 OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE <br /> IN ND USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS----- "'""1- <br /> a- of Well Excavation Dia. of Well Casing <br /> n In t�SI ❑ Op�n Bottom © Manteca �� , <br /> Fi , T�• Lft, I�,r.SERVICES <br /> (.1 D ! ri to L] Gravel Pack C]aTracy YPe <br /> I'1 Pu I1 Other [-1 Delt Depth of Groulai--- `''" ttiL �� <br /> I I Ifr t —Approx. Depth t I Eastern Surface Seal Inst d by ��]] <br /> H.P. <br /> Stat eJr- <br /> Repa' k e L7 Type of Pump 3ea1 Ftaterial & Depth <br /> Well c ❑ Well Diameter <br /> DeplhI Filler Material & pth <br /> TYP WORK: NEW INSTALLATION I I REPAIR/ADDITION-FF-DESTRUCTION f allolls septic <br /> systwithe 0permitted <br /> r tted if public sewer is <br /> ` / 0 <br /> In kl a I serve: Reside' <br /> Commercial Other 12G. 9-41 <br /> N o ' 'ng units: Number of bedrooms_01— 11111112 <br /> Water table depth <br /> C rkf oil to a depth of 3 feet: <br /> SEP A%4 D Type/Mfg � Capacity No. Compartrnenta <br /> E -Method of Dispo 41 <br /> PK AI PLT. 0 <br /> l Distance to nearest: Well V Foundation G Property Line <br /> ,IM <br /> LE ING LINE No. & Length of lines otal length/size <br /> FILR BED ❑ Distance to nearest: Well oundation Property Line <br /> I <br /> _ Number <br /> SEEPAGE PITSJ <br /> 't Depth Z Size 2 <br /> .IMPS LI Distance to nearest: Wel!F- Fotirttfation CJ Property Line <br /> DISPOSAL PONDS O �� ti <br /> San Joaquin county ordinances, state laws, an <br /> 7 hereby certify that I have prepared this application and that the work will8+ � f lr3 h 'FLICH'LAL ,H 8nV1C <br /> rules and regulations of the San Joaquin County ` Is Issued, I shall not <br /> Home owner or licensed agent's'signature certifies the following: "I certify that in thi signature <br /> employ any person in such manner as to become subject to workman's compensation I al ornis." Contractor s iring��s�p� orkmanonqact1seompensa <br /> certifies the following: "I certify that in the performance of the work for which this perm� MaLp oPE"II l <br /> tion laws of California." 11 <br /> The applicant st call for al ired ins pe, ions. Complete drawl 111110 on reverse side. �� �-- <br /> Signed <br /> t Title: ' Date: s <br /> 9 <br /> �!. FOS ENT USE ONLY 0 �, C <br /> Application Accepted by <br /> l".._ l T DateArea r <br /> Date Final Inspection by Date <br /> Pit or Grout Inspection by y �. <br /> Additional Comments. I _ <br /> _ ) 1 cite <br /> )iApp scant=`Re 1 �0:/� n Joaqutn-County putilic"Health'Services_--_��NR2- <br /> bf/3pReal rm <br /> �Z ftal <br /> �ry�M j�l iiiroSannJoaquin, p d tioxt2009,,iStkn, CA 95201171�f.J IV* ( U���J �u _ <br /> [i t� <br /> RECEIVED BY DATE ^tet PERMIT-NO. (,M1'c5f -"' r✓5 <br /> FEE CK <br /> INFO AMOU T DUE AMOUNT REMITTED CASH n 4 Qh ry 30.E <br /> . tEH 13.4{REY.t/h 51 <br /> EH t42a �`y / <br />