Laserfiche WebLink
1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 a <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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. j <br /> r C Ci - Lot Size/Acreage Q/ > <br /> Job Address L' <br /> Address Phone �-Z <br /> dd <br /> Owner's Name 7 <br /> Contract Address f License Ne. 5 ZY Z� Phone <br /> TYPE OF WELL/PUMP: NEW WELL 71 WELL REPLACEMENT Fl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER C3 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 f <br /> I <br /> Dia, of Well Excavation ' Dia. of Well Casing <br /> Cl Industrial C3 Open Bottom ❑ Manteca <br /> F7 Domestic/Private Cl-Gravel Pack 0 Tracy :Type of Casing_ Specifications <br /> `- �" Type of Grout <br /> I'i Public f-1 Other 'y ❑ Delta Depth of Grout Seal <br /> I ! Irrigation ""_.Approx. epth l l Eastern Sukriace Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done Q <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material & Depth <br /> Depth ti's Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW IfJSTALLATlON I i REPAIR ADDITION DESTRUCTION I l INo septic system permitted if public sewer is <br /> available within 200 feet.l w <br /> Installation will serve: Residence. _Commerciall= Other Y _ <br /> rt <br /> —`fVumbeFof-living units:= Nu�lir _r oma .� <br /> ater table depth <br /> Character of soil to a d,p3h of 3 feet <br /> SEPTIC TANK,4,-, Type`/Mfg t Capacity—,-, Compartments <br /> ` ' Method of Disppsai <br /> PKG. TREATMPL;/-1051 <br /> NT L . ❑- f <br /> ` <br /> Distance t nearest: Well s ^ Foundation Z f _ Property Line <br /> LEACHING LINE No. & Length of lines Q Tptal lengthtsize � x <br /> i Z <br /> FILTER,BED ° .n Distance to nearest: Well.,�"��:Faunclwion O '�- Property line•_ S ' <br /> � r.. <br /> SEEPAGE PITSDepth i. `" Size plumber l <br /> SUMPS LI Distance to nearest; Well Foundation Z-0 fi 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, state laws, and <br /> rules and regulations of the San Joaquin County r <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 to become subject I6 workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> i certifies the following: "I cenifyp <br /> `that in theerfdrmance of the work for which this permit is issued, I shall employ persons subject to workmen's compensa- <br /> tion laws of California." <br /> The appfican t call fo II r ed inspections. Complete drawing on reverse aid n t rj <br /> Signed X Title: V�J Date: <br /> y <br /> "FOR DEPARTMENT USE ONLY <br /> y fZr <br /> Application Accepted by Date Area <br /> I <br /> Pit Grout inspection by abate ` �Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San-.Joaquin County Public Health Services <br /> Environmental Health Permit/Servlces �N <br /> 1 445 N ,San.Joaquln O Box 2009;- Stkn, .CA 95201.*, \l(r11[1Iy� <br /> FEE AMOUNT DUE AMOUNT REMITTE CK ECEIVED By D TE PERMIT NO. <br /> _. INFO _. --- <br /> a EN13-24(FI EV.I/n5i 5 <br />. Eli 11.36 , <br /> �, n <br />