Laserfiche WebLink
l <br /> APPLICATION _ <br /> 1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 /V0 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> Nom`• c� ��.�:� <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 comliance with San Joaquin County Ordinance No. 51+9 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job AddressLot Size/Acreage �T X <br /> Vownot's Nsmen_ 1�� / Address Phone 2 76 Contractor Z dress 6a) e) <br /> License No. Phone <br /> TYPE OF WELL/PUMP: f NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well. 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well <br /> 11 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> �,1 <br /> INTENDED USE . TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> n Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing <br /> C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> f"1 Public CI 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 0 Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material b Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION (No septic system permitted if public sewer is <br /> Ii available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number Of living units: I� Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. D Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ! Method of Disposal ) <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No.0& Lengtli of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> II <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I� <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 r <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, ! 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 empioy persons subject to workman's compensa- <br /> tion laws of Cali <br /> T e 1pplican t 11 for all reglu i pe. ns. Complete drawing on reverse side. f f <br /> Signed X ' Title: Date: 4; <br /> -16 <br /> OR DEPARTMENT USE ONLY 1 <br /> Application Accepted by �- pate Area 0 Z <br /> Pit or Grout inspection by L Date Final Inspection by Data ! 3 , <br /> Additional Comments: ` lT Y( /� ✓/1t^ GLv[ Y'A4 C, <br /> O <br /> Applicant - Return alll`Mcopies to: San Joaquin Count5f public Health Se�rvic�A <br /> I Environmental Health Permit/Services 1 <br /> 445 N San Joaquin, ,P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT.REMITTED CK RECEIVED BY PATE PERMIT'NO. <br /> INFO CASH <br /> it <br /> • EH 1344 tpEV.t i Is 5 1 <br /> EH 14-28 - f p � � �y <br />.� If .O G VVV <br />