Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL IiEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EgPIRES I YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> Application to hereby made to San Joaquin County for a permit to construct and/or install the vork herein deicribod This <br /> application is made in compliance with San Joaquin County Ordinance No 5119 and 1862 and the Rules and Regulations of Sita <br /> Jonqufn County Public Health Services <br /> l <" <br /> Jnh Address _4 C ll�[t f w s !/ EC / _ L'ty ICC 1=r crJ lot SfzPrArrPagc <br /> r 4t fr I , i�(r� r ••ir++ rf l fit + ► /' �. If r 1 - - <br /> r] veer s Name Address It 7E C ' i t C 1.rr rr - It'. <br /> -- -7- ,..,. Phone <br /> y ( r r C ti81 y <br /> r"nti7ttor �1ZSfef"rJ� ���fZl♦✓f �=Y �f,(C1Npddre55 ( r,�,7( ' Jlu� ! S '7 7 7 Y <br /> >� tIcense No sS 1� _ Phone S <br /> T r pE OF WELL/PUMP NEW WELL Ll WELL REPLACEI'tFtIT DESTRUCTION I i Out of Service W-11 (1 <br /> PUMP INSTALLATION C SYSTEM REPAIR L-1 OTHER/�`q� Monitoring Well <br /> DISTANCE 70 NEAREST SEPTIC TANK SEWER LINES --- DISPOSAL FL� / "P�1pP'bNE 'u <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J` <br /> t lnriustnal Cl Open Bottom 13 Manteca Drs of Well Excavation /f_� Dia of WPII Casing 'T r <br /> C)omenre/Pnvaro" 171 Greve! Pack f) Tracy Typa of C,arno Sr �,(t l� _rt 4 SpeerntTtlons <br /> I MIMIC f I Other f] Delta Droth of Gtoul Seal _ Type of Grout (&,! ,T/e- <br /> I Irntlation — _ Appror Depth 1 I Eastern Surface Seal Installed by <br /> nPnair Work Done (] Type of Pump H P State Work Done \ <br /> Well Destruction (7 Well Diameter Sealing Materiel & Depth } 1 <br /> Depth Filler Material & Depth <br /> i <br /> TYPE <7F SEPTIC: WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I {No septic system permitted if public sewer is �4 <br /> available within 200 feet 1 <br /> Installation will serv.r Residence _ Commercial _ Other <br /> Number of loving units w— Number of bedrooms <br /> e Character of cull to n depth of 3 feet Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No Compartments <br /> rKG TREATMENT PLT ❑ Method of Disposal \ <br /> Distance to nearest We" Foundation Property Line <br /> LEACHING LINE C No & Length of Ime9Total length/size I <br /> FILTER BED f-1 Distance to nearest Well Foundation Progeny Line <br /> SEEPAGE PITS 11 Depth Site _ Number <br /> SUMPS It Distance to nearest Welli t <br /> Foundation <br /> prSP05Al PONDS ❑ Property Line <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin county ordinances slate laves and <br /> rules and regulations o} the San Joaquin County <br /> Home owner or fican,-d agent s srgnattire certifies the following I certify that in the performance of the work for which this permit is issued I shell not <br /> employ any person In such manner as to become subject to workman s compensation laws of California Contractors hiring or sub contracting s onature <br /> [edifies the following I certify that in the performance of the work for which this permit is Issued I shall employ persons subject to workman to compensa <br /> tion jaws of California <br /> The applicant mu ca�_fbt�a_lll pegq ed Inspection$ Complete drawing on reverse side 7 <br /> Signed X % 4L4t �a �L Title <br /> Date <br /> TMENT USE ONLY <br /> Application Accepted by7 <br /> r Date _It­� tea <br /> Pit or Grout Inspection by /!%�^ Dare _—111C- `n � ' > <br /> � Final Inspection by / � Data �' <br /> Arlditionst Comrr,enis <br /> Applilnnt - Rpfttrn all roptp-; to San Jonquin County Pnblir 11PAI th Servtrefi y <br /> Environmental Health PPrmit/Servfceg c ti / r <br /> 445 N San ]onqutnFEE p O jinx 2000 Stkn CA P5201 <br /> AMOUNT bUE AMOUNT itEMIT1Ep CK <br /> INFO CASH RECEIVED BY DATE PI;PMlII NO <br /> t4l/ iii <br /> —K <br /> L✓ <br />