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 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) 113 <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 Address '"" " City^k Lot size/Acreage <br /> Owner's Name <br /> +r� -ice L f Address [ J i' !) �f, 41f V_r Phone".. � — S <br /> Contractor �' fay�r �' Address- 4 ` s License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> FI Domestic/Private O Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destructll0r' O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I !PAI /ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> yy available within 200 feet.) <br /> Installation will serve: Residence n Commercial_ Other <br /> Number of living units: _I Number of bedrooms I <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg A Capacity- No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> r <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE (9 No. & Length of lines <br /> Total length/size ' <br /> FILTER BED ❑ Distance to nearest: Well ,0& Foundation f fi ° Property Line 6 Q <br /> SEEPAGE PITS 14""Depth �./�� Size Number <br /> SUMPS LI Distance to nearest: Well , ! Foundation t Cf ' Property Line <br /> DISPOSAL PONDS O <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 <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." <br /> The applicant must9A4,L�,_t <br /> I for all required{,"' spections. Complete drawing on reverse side. <br /> Signed d%, V r` n Title: Date: j -�`i y 'y <br /> FOR RV"TMF,,NT USE ONLY <br /> Z= e� 2 <br /> Application Accepted by orate Area <br /> . 1 z <br /> Pit or Grout Inspection by Date Final Inspection y `� Date' <br /> Additional Comments: e Q tw U 5,,, <br /> Applicant - Return all copies to: San Joaquin County Public Hea, h Services 04w Y` <br /> Environmental Health Permit/Services lL o� ks— <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 952014Q S <br /> FEE AMOUNT DUE AMOUNT REMITTED I C K RECEIVED BY DATE PERMIT'N0. <br /> INFO <br /> . EH 13.21(REV.I/x s <br /> EH 14.20 c►�.JO� <br />