Laserfiche WebLink
SAN JOAQUIN COPONTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> / I 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> \ � <br /> ^� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �✓ L (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. <br /> Job Addressr - City�G� Lot Size/Acreage <br /> r 04 <br /> a t d <br /> Owner's Name ddress "� Pone <br /> Contractordi Addres /T-0_,Cft0License NoJ Phon <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR OTHER O 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 O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing S _, <br /> 14 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications V <br /> II Public El Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. De I Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. / State Work Done <br /> Well Destruction O Well Diameter Sealing Material a Depth <br /> Depth Filler Material a Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <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 Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 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 Calif " <br /> The applica must all for all r7�� <br /> pection Complete drawing on rever 'de. <br /> Signed X Title: _ ! Date: /�7 <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by 1 Date Area 2 <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 CK RECEIVED BY DATE PERMIT'N0. <br /> INFO CASH <br /> . 00 <br /> EH 13.24(REV.iies) , 0 f_ A A Z <br /> EH 114.25 <br />