Laserfiche WebLink
SAN JOAQUIN COUNTY 141C*HEALTH SERVICES <br /> `b V ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> I <br /> Q �✓ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> C (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 Address City _ t'^_ Lot Size/Acreage <br /> Owner's Name j6 Address Phone <br /> Of <br /> f,� <br /> len <br /> Contractor Address jrazw; License N ,L_� honefi4;4V�R_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION Ll Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES'. DISPOSAL FLD, PROP. LINE <br /> k <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia+of Well Excavation Dia. of Well Casing <br /> XDomestic/Private ❑Gravel Pack Ll Tracy Type of Casing_ Specifications <br /> r. <br /> I'1 Public I'1 Other , r Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation _�Apprgx, Depth i Eastern Surface Seal Installed by <br /> Repair Work Done X Type of Pump H.P. 9= _ State Work Done,,._ <br /> Well Destruction ❑ WeN Sealing� Material & Depth <br /> Depth Filler Material & 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 /> p •` 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 off3 feet: _ —Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> k �{ <br /> PKG. TREATMENT PLT. ❑ -~ -~ - - u .!. ,Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl Na.'&;Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation "Propeity Line <br /> SEEPAGE PJTS 11 Depth, Size'_ '- * Number <br /> SUMPS f.) Distance to nearest: Well Foundation Property Line <br /> DISPOSAL 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, stale 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'per`mit is issued, I shall not <br /> employ any person in such manner as to become subject lo`workman's-conypensation 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 c pensa- <br /> tion Is of <br /> w <br /> The +cant mu all- for all requ' pecti Complete drawing onve a side. <br /> Signed X Title: Date: - <br /> OR DEPARTMENT USE ONLY <br /> .3 <br /> Application Accepted by Date L Area <br /> Pit or Grout Inspection by Date Final Inspection by JA,140Date to <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, B x 2009, Stkn, CA 95201FEE <br /> INFO <br /> ppN 0 AMOUNT DUE AM UNT REMITTED CASH REC IVSD BY p TE PERMIT NO. <br /> + EH 1 <br /> 3-24 IREV.1/n51 yA <br /> EN 14•76 1 Y� <br />