Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> L� P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT ESPIRES 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 install the Work herein describ of This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and R <br /> Joaquin County Public Health services. <br /> X <br /> so City��9WL�� Lot Size/Acreage <br /> Job Address &�'_,.ice . .,u, ��i�AflF� Address Phone SOI�� <br /> Xwner's Name <br /> ! X14 License No. Phone <br /> /1t11,0� _Address <br /> ontractor,, DESTRUCTION Cl Out of Service Well ❑ <br /> TYPE OF WELL .UMP: NfW WELL ❑ WELL REPLACEMENT Monitoring Well L1 <br /> - , ' .A � .-. � SYSTEM REP ❑ OTHER•C] <br /> f ; PUMP INSTALLATIQN ❑ f <br /> DISTANCE TO ftIEAREST: SEPTIC TANK SEWER NES DISPOSAL FLD. PFOP. LINE <br /> ., FOUNDATION <br /> AGRIG LURE WEL OTHER WELL PITS/SUMPS <br /> ,, i <br /> INTENDED U9E TYPE OF WELL PROBLEM AR A� ON. RUCTION SPECIFICATIONS Dia. of Welt Casing <br /> C-1'Industrial ❑ Open Bottom �, Cl Manteca D . of Well Excavation Specifications <br /> f C7 <br /> Domestic/Private fi�y�Gravel.Pack , - ❑.Tracy ype f Casing y - <br /> Type of Grout <br /> j. <br /> It Pu�tic' f:l,Other. n Delta ' DeRth o Grout Seat i s <br /> I Iklrrigation Approx. D'aptti" I l Easlerri 5uria'ce Sett stalled by <br /> f --�P s <br /> Hr -•State Work Done <br /> Repair Work Done 12. ILTyps of Pump <br /> . -- - '- - r <br /> Sealing Material & Depth <br /> Well Destruction ? ❑ Well Diameter_ <br /> p�Pth Feller Materihl & beptYt',-. �•+ � <br /> E OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I'.DESTRUCTION I I availablelNo 'w thin 20c system 0 feet.)red 'f public sewer is <br /> r• .kI <br /> IDISPOSAL <br /> stallation will serve: <br /> Residence Commercial Others a/r✓c E- _/� 7� _ �` <br /> umbor.,.of_living-unitsy,J_ _ ,_Number-of*bedrooms� depth <br /> ter table <br /> haracter 016011 to a.depth of 3 feet' fcapacit - No. CompTIC TANK- -" ��YPe/Mtg. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: >(Well J.L_ Foundation Property Line <br /> Total length/sizepu� <br /> CHING LINE L1 No. & Length of lines ���TER BED CE Distance to nearest: X Welt Foundation 10 Property Line_1__�•!% Size ' NumberPAGE PITS Ij1Y Depthy MPS LI Distance to nearest: )(Well v� Foundation /l -- Property Line PONDS ❑ <br /> I hereby certify that i have prepared this application and that the work will be 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 /> certilies 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 /> r tion laws of California." <br /> fl The applicant call f r fired inspections. Complete drawing on reverse side. <br /> �5 . ' "- Date: <br /> igned Title: <br /> f F R DEPARTMENT USE ONLY <br /> nl T �„� _ Date �- Z Area <br /> Application Accepted by - <br /> Pit r Grout Inspection by <br /> Date Final Inspection Data/ <br /> 70*g1- <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 Hox 2009, Stkn, CA 95201 <br /> CK ° RECEIVED BY DATE PERMIT'NO. <br /> EEE <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> fff 111 �%2 -� <br /> . EH 13-241tIEV.i/e51 S� 1) y,p o <br /> EH 14-20 1 <br /> 3 <br />