Laserfiche WebLink
{ <br /> a <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> t 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 made to San Joaquin County for a permit to construct and/or instal2 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 /> ( . <br /> Joh Address � City _ ���Lot Size/Acreage <br /> [ _ <br /> Owner's Name Address <br /> 1 .14.Co� , Phone <br /> Ad (f Q- <br /> 5-1 <br /> Contract Address v t �r � 7t9 ! ���-_ License No. 7D 2-� Phone �'u a <br /> TYPE OF WELL/PUMP. NEW WELL D WELL REPLACEMENT C3 DESTRUCTION 0 Out of service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR U OTHER O Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> " INTENDED USE- TYPE OF WELL -;- PROBLEM AREA—CONSTRUCTION SPECIFICATIONS ,_ �•-�. ,�a��� <br /> j C) industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i <br /> N Domestic/Private CJ Gravel Pack Ll Tracy Type of Casing_ Specifications <br /> i <br /> FI Public Cl Other P Delta Depth of Grout Seal Type of Grout <br /> I J Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ <br /> Well Destruction 0 Well Diameter Sealing Material,&.Depth` <br /> Depth ller Material & Depth [�l, <br /> i VV <br /> ! TYPE OF SEPTIC WORK: NEW INSTALt,ATION I REPAI /ADDITION. DESTRUCTION I I-1No-septic system.permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Re idence_ Commercial a Other <br /> Number of living units: 77 Number of be oms <br /> Character of soil to a depth of 3 feet: Water table depth w <br /> i <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments `y <br /> PKG. TREATMENT PLT. ❑ i .Y Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ` LEACHING LINE o. & Length of lines Total length/size <br /> FILTER BED CJ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size__ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ G' <br /> I hereby certify that I-have.prepared this application and that the work willrbe done-in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the-San 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: ','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 f ail eq d inspections. Complete drawing on reverse srd <br /> . <br /> - Q_ <br /> Date: <br /> Signed "Title t <br /> L FOR DEPARTMENT USE ONLY <br /> Application Accepted by 1 w Date Z? <br /> Pit or Grout Inspection by Date Final Inspection by A4 <br /> Additional Comments: <br /> Applicant - Return all copies to: - San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> :- 445 N San Joaquin, P 0 Box 2009, Stkn, CA"95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . EH 13-24IREV.FiHs) a <br /> EH 14-n00 <br /> k <br />