Laserfiche WebLink
0 <br /> 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 /> PERMIT E%PIRES 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 coWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> Owner's Nam Address Phone <br /> Contractor Address License Ido, s Phone <br /> TYPE OF WELL/PUMP: rd NEW WELL ❑ WELL REPLACE N DESTRUCTION -Dut of service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM R PA1 OTHE p Monitoring%Well <br /> _DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES# DI POSAL FLD �PROP_.LINE_J. v w - <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE F WELL PROBLEM AREA CONSTRUCTION SPECIFICATION r It <br /> n Indu pen Bottom 0 Manteca Dia. of Well Excavation _ Dia. of Well Casing <br /> omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing-. Specifications_. <br /> I') Public 1-1 Other r❑ Delta Depth of Grout.Seal Type of Grout <br /> I i Irrigation -Approx, De I t astern Surface SeA installed by <br /> Repair Work Done LJ of Pump � N.P. / S[ a ork D e <br /> Well Destruction Well Diamete �+ Sealing aterial & Depth <br /> Depth Filler Material & Depth . <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION'►I REPAIRIADDITION i I DESTRUCTION i I INo septic system permitted it public sewer is C <br /> �y available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water (able dep4fi <br /> SEPTIC TANK ❑ Type/Mfg Capacity• No. Compartments � <br /> PKG. TREATMENT PLT. ❑ Method of Disposal f l <br /> Distance to nearest: Well -Foundation Property Line <br /> LEACHING LINE Ll No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well sFoundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> 4 <br />-}- -SUMPS— ter' Ll- Distance to nearest: Well . -- Foundation- . Property Line.. <br /> DISPOSAL PONDS -- Cl—-_ <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 compensation laws of California." Contractor's hiring or sub-contracting signature . <br /> certifies the following: "I certify that in the performance of the work for whit h this permit is,issued, I,ahall employ persons subject to workman's compensa- <br /> tion laws of California." . _ _glz� <br /> .� .. �.. <br /> The applicant m cs E for II r i in tins. Complete drawing a <br /> Signed r Title: Date: - r <br /> F DEPARTMENT USE ONLY ' <br /> Application Accepted by r, Date 7-/- !2_ Area <br /> r <br /> Pit or2GouCt1n.rpactionby Date�� Final Inspection byDate <br /> Addisents: q <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> INFO FEE AMOUNT DUE AMf/OUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13.24(REV,im5 d f FQ 4a'� j� 174 [� <br /> EH 14.26 -7i `- ' <br />