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 /> r <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 Health Servicee. <br /> t4 Job Address 5 �� City SA9 fS? Lot Size/Acreage <br /> r 9216 � k!o Phone <br /> Owner's Name+. �+0+ 1 Address �I I <br /> Contractor Pvop �QSs • �27 �s;rr �" W' License No, � Phone <br /> TYPE OF WELL/PUMP. NEW WELL 0 WELL REPLACEMENT Cl DESTRUCTION Out of Service Well 0 <br /> PUMP INSTALLATION C7 SYSTEM REPAIR ❑ OTHER 0 Monitoring Well U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL—'PITS/SUMPS- <br /> INTENDED <br /> PITS/SUMPSINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] Industrial ❑ Open Bottom C3 Manteca Dia.of Well Excavation Dia. of Well Casing c� <br /> f7 Domestic/Private 0 Gravel Pack n Tracy Type of Casing_ Specifications <br /> 1'1 Public CI Other i n Delta Depth of Grout Seal Type of Grout <br /> jiTrrigallon __Approx. Depth Itl Eastern Surface Seal Installed by » _ I <br /> Repair Work Done U Type of Pump V. H.P. State VPork Done <br /> Depth <br /> Well Destruction � � f/ Sealing Material & Depth <br /> Weif Diameter _ <br /> p ?_ Filler Material & Depth <br /> 11,44 OF SEPTIC WORK: NEW INSTALLATION 1 REPAIR/ADDITION i I DESTRUCTION I I It-to sep is system peimitted if public sewer ' <br /> available within 200 f4 <br /> 92 <br /> Installation wi flesidenca_ Cornmercial_ Other <br /> Number of <br /> If <br /> units: umbar of bedrooms ! I <br /> Character of soil to a.depth of 3 feet: Water depth <br /> SEPTIC TANK ❑W Type/Mfg Capacity o. Compartments <br /> PKG. TREATMENT PLT. C1 Method of Disposal F <br /> Distance to nearestLiWell dation Property Line f <br /> { <br /> ti <br /> LEACHING LINE C1Hath of line';-,' - � Tors h/size <br /> FILTER BED Distance to nearest: i ",-Well Foundation Propert <br /> SEEPAG S I1 Depth Size Number <br /> SU LI Distance to nearest: Well Foundation .Property Line <br /> SPO <br /> SAL 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 w <br /> rules and regulations of the San Joaquin County I ` <br /> Home owner or f' a nt's signature certifies the fol Ing; "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any pe on in such neer as to become aubj t orkme'ri's compensation laws of California." Contractor s hiring or sub contracting signature <br /> certifies the f lowing: "I rtify that in the a a o- h6'work for which this permit is issued,cl shall employ persons subject to workman's compensa- <br /> tion laws of alifarn '!�/ F..• <br /> The applic call r all re it om drawing on r de. <br /> 1 <br /> Signed Title: Date: <br /> R D <br /> USE ONLY <br /> Application Accepted by � � Date KI Z� Area <br /> Pit or Grout Inspection by <br /> n Date/ j Final Inspection by `�� A /J Data) $J� q2 <br /> Additional Comments: ! a q p�6 riV I d'7 f a IPA L�r11.Grr L Cc�t�+ -1.0 Gl/f rrU,��Kx LfJ�P.�t .`"L.— �f Z d/?z!� <br /> Applicant----Return'-a:ll c'op"Y'es'to San"Jaaquin'Couri y pu lic�Tealtti Services W +h <br /> Environmental Health""Permit/Serilces <br /> 445 N San Joaquin, P 0 $ox 2009,�Stkn, CA 9520i" (J t <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMrT'NO71/� <br /> . EM13.24IREV.Irtssl WD �I7,n0 & d�Gb 230 <br /> EH 11.26 V5 <br />