Laserfiche WebLink
4 <br /> t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application in 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. �t <br /> 1016-Job Address 4707 F�r'_i fic. iV Q' D City S Lot Size/Acreage 3,,000 sq, ft. <br /> Owner's Name UrIOCal AddressP_O. BOX 5155, SM Ra=,,CA 9+583 Phone - <br /> Contractor I4teX AddressP.D. BOX 1664 W.Sacraxnto, CALicense No55ZL95—Pho4 <br /> TYPE OF WELLIPUMP: NEW WELL M WELL REPLACEMENT E 1 DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER M �Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. L` test wan <br /> FOUNOATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 12 in Dia. of Well Casing 6- <br /> in-[I Domestic/Private 10 Gravel Pack 0 Tracy Type of Casing . GQ-M Specifications <br /> I'I Public I:1 Other f1 Delta Depth of Grout Seal 5D ft- Type of Grout-N1QAt' ('Fr Pat' <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal installed by driller <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material L Depth lentmita_ 7-�Q gmit to Q,rFace <br /> I Depth Filler Material 3 Depth 23 &atea� Gard <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION t I iNo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial____ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line l <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number C, <br /> , <br /> SUMPS Ll Distance to nearest: Well Foundation 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 <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 as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following-, "I certify that in the performance of the work for which this permit is issued, t shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant st cal or all r it in tions. Complete drawing on reverse side. <br /> Signed X Title: —_Owner Date: .Il] u 2%, 19A7 <br /> R DEPARTMENT USE ONLY (,, G �y `• <br /> Application Accepted by Date�^��f ILL"'n� 1 Z_- Area �n <br /> Pit or Grout Inspection by Date V ' �3 R� FinalInspectionby./I! '1 Date �'I <br /> Additional Comments: 1 T 1 wQ�t t 1 <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK V CRECEIVED BY �[7� DATE�] PERMIITT'NO. <br /> . EH 13-24IREV.i 1151 � DO 2CA/SH� �rfy J �� v,� ♦�• f q1i­Z4'X <br /> EH 14-A / I <br />