Laserfiche WebLink
~ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> t <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> s (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in cor*11 nce vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health <br /> P� is <br /> Job Address ' P "`Y "r r y Lot Size/Acreage <br /> ' Owner's Nam Address Phone 'M ' <br /> Cor,itrac o ddressLicense No. ��L' PhanO�• 7,0 <br /> TYP.E'OF WELC7PUMP: -- _ NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION U Out of Service tr'ell 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well C7 <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 - .� <br /> n Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing ` <br /> [J Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing- Specifications <br /> I'1 Public El Other 1­1 Delta Depth of Grout Seal Type of Grout �1 <br /> I #Irrigation _.Approx. Depth I 1 Eastern Surface Sedl Installed by <br /> Repair Work Done U Type of Pump H-P. State Work Done_ 11 <br /> Well Destruction ❑ Well Diameter Sealing Material dr Depth <br /> Depth Filler Material b 'Depth <br /> TYPE OF SEPTIC WORK: NEW INSTAL TION 1 1 REPAIRIADDITION ' DESTRUCTION i I INo septic system permitted if public sewer is <br /> available within 2t0 feet.1 <br /> Installation will serve: Re 'dance l Commercial_ Other <br /> f <br /> Number of living_uniis;_ Number-of-bedr = _ — _ - - _ __ <br /> Character of soil to a depth of 3 feet: r Water table depth <br /> SEPTIC TANK. 0 Type/Mfg J Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ I r Method of Disposal <br /> Distance_to nearest: Wali Foundation Property'Line <br /> LEACHING LINE No. 8 Length of lines Total length/size <br /> r f �t <br /> FILTER.BED n Distance to'nearest: Wel! _ Found'ation Property Line <br /> SEEPAGE PITS Depth Sire_ Nrmber <br /> SUMPS C) Distance to!nearest: Well A00 r Foundation [_ Property Line <br /> DISPOSAL PONDS 0 <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 - '1, ; <br /> Home owner or licensed agent's signature certifies the following; "I certify that'in the performance&-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-cbmpansation 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 Ihis_permit'is issued, l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m call for squired inspections. Complete drawing on reverse id <br /> Signed X __ TiNe=�- ` Date: AA1 <br /> 6 - FOR DEPARTMENT USE ONLY <br /> a� -7/ <br /> Application Accepted by•i f�' ��' Date ���J Area p` r <br /> or Grout Inspection by Date` . Final Inspection by 4��a:1-a Date <br /> Additional Comments: r <br /> Applicant - Return all'copies to:r San Joaquin`County Public Health 4Servi-oes <br /> Environmental Health Permit/Services ' .;;r b <br /> { 445 N San Joaquin,L�P O-Box 2009, Stkn,-SCA 95201. <br /> FEE AMOUNT DIJE ..- -AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> /.)��_ <br /> . EH 13.24 IREV.I I A 51 <br /> EH 14.26 ( LLL <br />