Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 S CANNED <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 Health services. f�i_1eAJC_1a' <br /> �,L Gc1' F�Do A _— City P— Lot size/Acreage l�x R <br /> Job Address _. <br /> Owner's Name <br /> 1 L O Address Phone <br /> Contractor <br /> Ca /tJ Address License No. 9�` Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well C <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR LlOTHER ❑ Monitoring Well <br /> DISTANCE TO 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 /> n Industrial C3 Open Bottom C] Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fa Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'i Public Cl Other 171 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 U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION EP <br /> RAIR/ADOITION I 1 DESTRUCTION I I afvailableo septtic system <br /> m teeth <br /> / ed if public sewer is <br /> Installation will serve: Residence�/ Commercial _ Other �r *F i2E Go,r✓2> PA)OQ <br /> Number of living units: ---L. Number of bedrooms 3 7`O / 9 7'2- <br /> Character <br /> '2-Character of soil to a depth of 3 feet: SddzD Water table depth <br /> SEPTtC TANK ❑ Type/Mfg e 9L 4- Capacity 1Z00 No. Compartments 2- <br /> PKG. <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well SO Foundation :SK4 Property Line �9 r <br /> LEACHING LINE L`r No. 8 Length of lines ` ® Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Sd Foundation Property Line <br /> SEEPAGE PITS I'I Depth Size Number <br /> SUMPS ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby cenify 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 workmen'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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> FO�yDEPART NT LiSE ONLY <br /> Application Accepted b Date <br /> Pit or Grout Inspection by Date Final Inspection by Data <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 CASH RECEIVED BY DATE PERMIT'N <br /> INFO O. <br /> . EH 13-741REV.i/H 3 eD <br /> EH 14.70 <br />