Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I 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 Health Services. w <br /> Job Address a- 9V �`1�Z City Lot Size/Acreage ��-�-�— <br /> Ownef's Name Address �'� �— Phone <br /> Contractor Saz� Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL RE CEMENT 17 DESTRUCTION ❑ Out of service Well '❑ <br /> PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ OTHER Cl Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom x ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> CI Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications Q <br /> I'I Public 1-7 Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.._..Approx. Depth l I Eastern Surface Seal Installed`by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction D Well Diameter Sealing Material & Depth _ t <br /> < v <br /> Filler Material & Depth <br /> Depth - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I DESTRUCTION I 1 INo septic system permitted if public sewer is ; <br /> available within 200 leel.! <br /> .Installation will serve: Residence_X Commercial _ Other ( A} <br /> Number of living units: ---,L Number of bedrooms r V <br /> Character of soil to a depth of 3 feet: Water table depth. <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' <br /> PKG. TREATMENT PLT. ❑ Method of Disposai <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Tot ai length/size p <br /> IF <br /> FILTER BED ❑ Distance to nearest: Well _ Foundation •� Line &,— <br /> Property l3 <br /> SEEPAGE PITS I I Depth Sire Number y <br /> SUMPS Lh�,Distance to nearest: Well 10 Foundation 40 4� - 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, a d <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." i <br /> The applicant ca all requi d insPe.ction Cc to drawing on reverse side. <br /> Signed itle: , <br /> /�z� -fx Date: / h3�'� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �+�- ���_ Date "��q2 Area <br /> Pit r Grout Inspection by 1 Date L Final Inspection by Date <br /> Additional Comments <br /> Applicant - Return ah1 copies to: 'San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> . .445.N San Joaquin,•P 0 Sox 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DtJ7E AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EH t3-241REV,rinse <br /> FH 14.2e r <br />