Laserfiche WebLink
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 1$62 and the Rules and Regulations of San <br /> Joaquin Count Public <br /> oaq y c Health Services. <br /> Job Address 16 I � ��1 U�� �QQ� Cityr <br /> Lot Size/Acreage <br /> Owner's Name Address JZ 1©3 C_ Pb40 f h r Y :D r" Phan 7 <br /> Contractor r Address Pd 1 /d am License No,�_ Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT I7 DESTRUCTION ❑ Out of service Well <br /> PUMP INSTALLATION O SYSTEM REPAIR D OTHER ❑ Monitoring Well <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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �j <br /> Cl Domestic/Private L1 Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> i'1 Public 1-1 Other fl pelta Depth of Grout Seal Type of Grout <br /> ! ) Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth ; <br /> Depth S- Filler Material A Depth \ I <br /> TYPE OF SEPTIC WORK: -NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is i <br /> . available within 200 feet.) <br /> installation will serve: Residence Commercia—1 , <br /> — Other "° N <br /> Number of living units: Number of bedrooms <br /> Character of=soil to a depth of 3 feet:_� ._. �✓rV �,f .,=___ _ Water table depth <br /> SEPTIC TANK- ❑ Type/Mfg CapacitAF y _ No. Compartments <br /> PKG. TREATMENT PLT. 0 � Method of Disposal <br /> Distance to nearest: Welles��Foundation Property Line <br /> LEACHING LINE ' No. & Length ai lines / Total length/size /`-�:7` <br /> FILTER BED 0 Distance to,nr earest: Well ,L� Foundation Property Line G:Z2/=R-- <br /> SEEPAGE PITS F � <br /> 11 Size thf fNumber <br /> SUMPS )m� Distance to nearest: Well c�=tdfp Foundation 41 Property Line <br /> DISPOSAL PONDS O <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 compensationlaw's, of California." Contractor's hiring of 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.laws of California." �,- <br /> The applicant must call for all roquired inspections. Complete drawing on reverse side. <br /> Signed ?L—_�� � .._ °Title: _ Dater }` <br /> FO IE ART_ USE LY }� <br /> Application Accepted by •�-r_ 1 Date a <br /> Pit or Grout Inspection by Date Final Inspection b Data <br /> Additional Comments <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Bnvironmental'Health Permit/Services <br /> 445 N..San Joaquin,..P O Box 2009, Stkn, .CA 95201 <br /> FEE{ AMOUNT-DUE '^" AMOUNT REMITTEDCK RECEIV p DYE PERMlT'NO. <br /> IN FQ/ H <br /> EK IYK <br /> 19.71(REV,trsl <br /> H <br /> EH 11128 • f ��.� <br />