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 /> 1�. <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. <br /> tj <br /> Job Address ' / pot—,t 7111 City r"%-"tom« Lot Size/Acreage <br /> Owner's Name &L9,er<'r f91z f.C?CIA Address L " rPhone Z� /• I2r�' <br /> Contractor S c L_ P' Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <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 /> [.l <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> Public (.1 Other F1 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 Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION I I INo 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 J- / <br /> Character of soil to a depth of 3 feet: � to Y 0 ' ` ' Water table depth <br /> SEPTIC TANK C4--Type/Mfg �� L �d„a ie"i �L_ Capacity Za 0 No. Compartments <br /> PKG. TREATMENT PLT. ❑ / Method of Disposal .,re" <br /> Distance to nearest: Well (c)U ' Foundation Property Line a 6' <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 11,o Distance to nearest: Well n FoundatioProperty Line <br /> a ; X I b PaT'er 6cza z r±.,cfi< a—®..2,- Pc- <br /> SEEPAGE PITS I I 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, 1 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 applicantmust,call for all requ' d inspections. Complete drawing on reverse side. <br /> Signed XT�l � —��� Title: Date: /�/ <br /> FOB DEP RTMENT SE ONLY <br /> Application Accepted by Date Are ��/ <br /> Pit or Grout Inspection by Date Final Inspection by <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 RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . EH13.2 (REV.riNsl <br /> EH 14.26 <br />