Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
i <br /> SAN JOAQU I N 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 6t %%X <br /> i <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUID <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. <br /> Job Address ��761 � �� � City Lot Size/Acreage" C Tt✓v <br /> i <br /> Owner's Name Address 346 `� " Zi—W C- Phone � — 9/73 <br /> Contractor Address _ 5S/ -License,No.- Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION o Out of Service Well ❑ <br /> u: <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ Monitoring Well L7 <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 /> F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack D Tracy Type of Casing_ Specifications <br /> I'I Public L7 Other 171 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I l Eastern Surface Soul Installed by <br /> Repair W Done ❑ Type of Pump ,- H.P. State Work Done , r•- +� a <br /> Work <br /> Well Destruction ❑ Well Diameter Sealing Material h Depth aJr~f� <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION U, DESTRUCTION I I tNo septic system permitted if public sewer is t <br /> available within 200 feet.l <br /> l <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms (� <br /> Character of soil to feet: Wat epth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ 1 Method of Disposal <br /> Distance to nearest: Well un Property Line <br /> LEACHING LINE 0 No. & Length of ' Total length/size <br /> FILTER BED ❑ Distan nearest: Well Foundation_ Property Line <br /> In SEEPAGE PITS I t Depth Size Number 1" <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 /> Horne 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, l shall employ persons subject to workman's compensa- <br /> tion taws of California." + <br /> The applic;arust call for all required ins, lions. Complete drawing on reverse side. <br /> Signed XTitle: - Date: ^ �� <br /> :,FOR DEPARTMENT,USE ONLY <br /> Application Accepted by Pai h - Area <br /> Pit or Grout Inspection by Date Final Inspection by DateD <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 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED FI RECEIVED BY DATE PERM17'NO. <br /> INFO r�! <br /> . EH 43.24{REV.i/n 5S /I 'T T /` <br /> EH 14-M at <br />