Laserfiche WebLink
j <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> k. P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I 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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services�.J}�f y� <br /> Job Address _ �++ - �• pa Com► A44, City �F � Lot Size/Acreage 1(1 <br /> Owner's Name]�r� � rj� � dd�mess Phone ' <br /> Contractor Address � 1 / � f V License Ho.� S phone �L-` <br /> TYPE OF WELL/PUM : NEW WELL ❑ WELL REPLACEMEN DESTRUCTIOlqulkOut of Service Well [_l <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _j <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS er <br /> C1 Industrial pen Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing <br /> �Damestic/Private 0 Gravel Pack7 ❑ Tracy Type of Casing_ Specifications ° I <br /> I'I Public C7 Otherr9ol n pelta Depth of Grout Seal -- Type of Grout--- - <br /> I I IrrigationZ�- .Appix. Depth i I Eastern Surface Seal Installed by 101 ��ti'Leol.T` <br /> Repair Work Done LJ Type of Pump H.P. State ork Done `� <br /> Q« Sealing Material & Depth <br /> /��[ Well Diameter <br /> Well Destruction rL Ip <br /> -Depth_ __ Filler Material & Depth O <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation'will seriie:^'Residence='Cdffr60cial-_-- '°Other - -^^�-•--T - - - . <br /> Number of living units: Number of bedrooms ' <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments i <br /> PKG. TREATMENT PLT. ❑ _ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> -LEACHING LINE Cl,-No: & Length of lines Tata) length/size <br /> FILTER BED } C7 ,Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth.---- Size _ Number <br /> SUMPS LI ¢Distance to nearest: Well 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 <br /> Home owner or licensed agent's signature candles the following: "I certify that in the performance of the work for which this permit is issued, I shall not i <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 employ persons subject to workman's compensa- <br /> tion taws o*fo <br /> The applic .in ctions. Co drawing on reverse stdSigned XData:FOR DEPARTMENT USE ONLY <br /> Application Accepted by a / Date &49Area G <br /> Pit a rou Inspection.by Dale_J ,H/7 G Final Intion by Date <br /> Additional Comments: sp ✓ <br /> Applicant - Return all copies to: San Joaquin County Public He Services <br /> Environmental Health Permit/Services h <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> CKI <br /> INEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMiT'NO. <br /> . EH 17.24 IREV.l/ns! <br /> t! <br /> EH 14.26 _.:.'a�.- r r✓! �� (y <br />