Laserfiche WebLink
a <br /> a <br /> 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 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 Heealljth Services. <br /> Job Address 9 A / 7 r=-��Ar41`5 Ael city j���G Lot Size/Acreage <br /> Owner's Name OA✓e JFG� _ Address Phone <br /> 1 <br /> Contractor 'AWAV <br /> N' 5*0N Address 066 Lveff u VA License NoW 9rZ Phone <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE 70 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 /> C1 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing '•y <br /> Ca Domestic/Private ❑ Gravel Pack ❑ Tracy ',r Type of Casing_ Specifications <br /> F] Public I-1 Other C"1 Delta Depth of Grout Seal Type of Grout <br /> I I Ifrigation —.Approx. Depth l I Eastern Surface Seal Installed by \Q <br /> Repair Work Done ❑ Typepl Pump H'.P. State Work Done T w <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIAODiTION I I DESTRUCTION I 1 iNo septic system permitted if public sewer is <br /> available wilhin 200 feet.t <br /> y installation will serve: Residence A— Commercial Other - <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:; 'dd064� ` --Water table depth <br /> SEPTIC TANK 0 Type/Mf i'.P" C.4$r Ar� �'G VO � <br /> g . Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ , Method of Disposal } <br /> Distance to nearest: Well :«a Foundation z Property Line -"-* <br /> LEACHING LINE IV No. & Length of lines Total length/size �►O <br /> FILTER BED F1Distance to nearest: Well' 41414 Foundation Property Line <br /> SEEPAGE PITS 11 Depth size 1+ �4 Number IV r1 <br /> SUMPS If 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 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 subject1to 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." rj <br /> The applicant mu tcall for all required inspections. Complete drawing on reverie side. <br /> Signed X cel °•Title: Date: <br /> t•• <br /> OR ART S -ONLY <br /> Application Accepted byDate Azsa <br /> Pit or Grout Inspection by Date Final Inspection by Datd� <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 O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> RECEIVED BY, p E PERMIT'NO. <br /> INFO/ <br /> . EN 3..28 24(REV. <br /> EH 14lll...���"""' / i O C/�[/ "C/ <br />