Laserfiche WebLink
8�- 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 /> Pco,--K10 �Q a- c, PERMIT MIRES 1 YEAR FROM DATE ISSUED <br /> �' <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 Servic <br /> Job Address ,,��11 <br /> 4Q 1 O� -eT City t Lot Size/Acreage <br /> 1—.-�f , --, <br /> c` <br /> Owner's Name Y Address SckG ate- v Phone <br /> Contractor.' a Address - ac-1�-ova ""License N hone$,9 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR)t OTHER O Monitoring Well C7 <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 /> Cl Industrial 0 Open Bottom O Manteca Dia. of Well Excavation Dia. of Wel)Casing <br /> 'Domestic/Private, - 0 Gravel Pack7 O Tracy Type of Casing_ Specifications <br /> I'1 Public 1,-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. De I I Eastern Surfs Seal Installed by <br /> Repair Work Done '� Type of Pump ,1. H.P. LAi�z!;_ C_ <br /> State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: -NEW INSTALLATION I I R FAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> r available within 200 feet.) <br /> Installation will serve: Residence- Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to.s depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. b Length of lines Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sue Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 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 /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to;kman's ompensa- <br /> tion laws of C ' <br /> The appli must call r all required i ions. Complete drawing on rover side. <br /> Signed Title: Date: <br /> OR <br /> ^ A .tom .f.DEPARTMENT USE ONLY <br /> Application Accepted by Date ` <br /> _ 1 "' area <br /> Pit or Grout Inspection by Date Final Inspection by Date� -X <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, Box 2009, Stkn, CA 95201 <br /> IFEE NFO AMOUNT DUE AM UNT REMITTED CK RE VED BY DA E PERMIT'N0. <br /> • EH 13-21(REV.1 i N SI a- rW1,91 <br /> EH 14.26 <br />