Laserfiche WebLink
SANEJOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> r _ _ `' • =ENV I-RONMENTAL 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 /> E Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> f application is made in tcnpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Service <br /> '�"� ` <br /> Job Address .,. /aX71 _ � City Lot Size/Acreage <br /> Owner's Name ��til Address Phone <br /> y <br /> Contractor <br /> ;' testi Address • nse No, Phone <br /> TYPE OF WELL/PUMP: € NEW WELL WELL REPLACEMENT 4r DESTRUCTION C} Out of Service Well ❑ <br /> Monitoring-Well <br /> Well <br /> PUMP INSTALLATI N µ�~ SYS7 A REPAIR OTHERT❑ I ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES POSAL FLD. PROP. LINE q <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _-i <br /> INTENDED USE_� .TYPE_OF WELL _PROBLEM AREA CONSTRUCTION SPECIFIC i41JS p <br /> r, s <br /> n to trial 1 pen Bottom ❑ Manteca IDrs: of Well Exc_avalion 'Dia:of-Well Casing- <br /> Domestic/Private Cl Gravel Pack* El Tracy �Typetof Casi g_ 5pecilication <br /> I'I Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> Iigetion=- - [.Appros. De 1.1 Eastern �S�irfac`e Sasl Installed by I y <br /> Re' air Work Done U Type of Pump - ,.� H.P. f State Work Done <br /> Well Destruction ❑ Well diameter ^ Sealing: erial & Depth <br /> Filler Material &Depth <br /> Depth, <br /> TYPE OF SEPTIC WORK: NEW>INSTALLATION I I REPAIR7�KODITION 1.1 'DESTRUCTION I i INo septic system peimitied if public ur, is vv <br /> available within 200 feet.l ...� <br /> Installation sersce: Residence_ Comrnarciel Other, <br /> Number of living units: '' Number_of bedrooms <br /> Character of soil to a depth_af3 feet: �� t Water table depth r <br /> SEPTIC TANK. ❑ `-Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ �.Y }} Method of Disposal j <br /> iDistance to nearest: Well Foundation coperty Line <br /> LEACHING LINE C1t.,,No& Length-of lines_- i Total length/size <br /> FILTER BED 0 Distanca to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I-l,�Depth Size Number <br /> SUMPS L1 , Distance to nearest: Well Foundation Property Line r <br /> f 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 SariJoaquin County <br /> ( Home own_er_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 compensatiomtaws of California.;.Contractor's hiring or sub-contracting signature - <br /> certifies the following: "I certify that' the performanee`of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> tion laws of California." r <br /> The applica t t all for all re ed in coons. Complete drawing on rer side, t• -�•-�------ y. <br /> ' I <br /> Signed i Title: Date: <br /> $ F R DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Dete <br /> Pit or Gjoyt Inspection by Date Final Inspection by <br /> { v t <br /> Additional Comments: <br /> t <br /> Applicant - Return all copies to: San Joaquin County Public ealth Services <br /> Environmental Healt�Perm t/Services <br /> 445 N San Joaquin2009, St&n, CA 95201 <br /> FEE AMOUNT DUE AMOU T R>M TTEt) CK HRECEIVED BY AT P RMIT NO. <br /> INFO <br /> - -- - � - <br /> . Era 17•21(REV.riKat r].� --s- - — <br /> EM 14-20 <br /> t <br />