Laserfiche WebLink
APPLICATION <br />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 />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 1662 and the Rules and Regulations of San <br />Joaquin County Public Health Services.-: l <br />Job Address • City 404ZAN— Lot Size/Acreage <br />Owner's Name �!�%.��/e�� Address Phone <br />tractor <br />Address <br />License No ,n 3� Phone <br />'PE OF WELLIPUMP: NEW WELL ❑ WELL REPt-ACEMENT 177 DESTRUCTION L] Out or Service Weil LI <br />PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well ❑ <br />STANCE TO NEAREST: SEPTIC TANK SEWER LINES " , DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL - i OTHER WELL PITS/SUMPS <br />IINTENDED USE <br />TYPE OF WELL <br />PROBLEM AREA CONSTRUCTiO SPECIFICATIONS <br />RECEIVED By <br />DATE PERM17'NO. <br />n Industrial <br />❑ Open Bottom <br />❑ Manteca Dia. of Well Excavation <br />•r <br />Dia. of Welf-Casing # <br />Specifications <br />1-i Domestic/ Private <br />❑ Gravel Pack' <br />❑ Tracy Type of Casing_ <br />t <br />Depth Grout Seal <br />of Grout <br />I"1 Public <br />171 Other <br />n Delta of <br />_Type <br />i 0Irrigation <br />_.Approx. Depth <br />I I Eastern Surface Seal Installed by <br />State Work Done <br />Repair Work Done f.] <br />Type of Pump <br />N.P. - _ <br />II Destruction ❑ <br />Well Diameter <br />Sealing Material & pepth <br />I <br />Depth <br />Filler Material'& Depth <br />OF SEPTIC WORK; NEW INSTALLATION I I REPAIR /ADDITION I I DEST <br />within 200 feet.) <br />installation will serve: Residence Commercial — Other <br />Number of living units: —4 Number of bedroo s t <br />Character of soil to a depth of 3 feet:/�,� t Water table depth <br />SEPTIC TANK. ❑ Type/Ml!fgg ;��� Capacityl _ No. Compartments <br />PKG:"TREATMENT PLT. ❑ i Method of Disposal <br />Distance to nearest: Well Foundation i 'Property Line <br />if public sewer: is <br />4 <br />3 <br />T-1 <br />G <br />LE <br />'ACHING LINE � �'"L� No'. &Length of lines r ; Total length/size 1%"� <br />' <br />„ 4 " <br />FILTER BED -s__ ""-4 Q—Distance to nearest: Well `4 Foundation Property Line ' <br />SEEPAGE PITS = IN I. Depth Size Number 1 <br />SUMPS Cl. Distance to nearest: Well Foundation Property Line., <br />DISPOSAL PONDS ❑ <br />�.l hereby certify that I have prepared_this,applicationland..that__thewwork will_be_done.in.accordance with` San Joaquin county ordinances, state laws, and <br />V, ruffs and regulations of -the San Joaquin County- <br />Hcma owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work -for which this permit is issued, I shall not <br />r 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 />is certifies the following: "I certifv that in the Derformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br />tion laws of California. <br />s <br />The applicagl mulit ca <br />`s <br />Signed X. <br />II <br />P <br />Application Accepted <br />Pit or Grout Inspectior <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 />i EH 13.24 WEV. 1 / N S <br />EH 14.26 <br />FEE AMOUNT DUE <br />INFO <br />AMOUNT REMITTED <br />CH <br />KS <br />CA <br />RECEIVED By <br />DATE PERM17'NO. <br />11137 <br />; fr�/f ! S L �V rQr <br />191 <br />f� <br />