Laserfiche WebLink
3' <br /> SAN JOAQUIN COUNTY -PUBLIC HEALTH SERVICES <br /> i 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 /> I (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:complience with San Joaquin County Ordinance No. 5h9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. 1 �7 <br /> Job Address _! ! wa r'1��'�� •-- ___ ._ City Lot Size/Acreage I / <br /> Owner's Name( t� ►�f` _� �W , - — Address J/ 3 0 4d �J[ l� if t_ Phone q& v O <br /> ysZy� , <br /> Contract44ddress , �� ' icense No. Z Z�Phone <br /> TYPE OF WELL/PUMP: NEW WELL C] WELL REPLACEMENT ❑ DESTRUCTION C) Out of Service 7e.11 0 <br /> -PUMP INSTALLATION ❑ - SYSTEM REPAIR-0 OTHER ❑ Monitoring Well C7 <br /> F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 <br /> F) Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications <br /> I'i Public 1-1 Other ❑ Delta Depth of Grout Seal _ Type of Grout <br /> I I Irrigation Approx. Depth I I`Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump �H.Pe f - - State Work Done <br /> Well Destruction -❑ Well Diameter 3eal3::ig kateritii C-Depth <br /> �! •.Depth - Filler Material 3 Depth , <br /> I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I IEPAIR DDITIONX DESTRUCTION ! I (No septic system permitted if public sewer is j <br /> Y - 11-11 . - - available within 200 feet.) <br /> Installation will serve: Residence_ Commercial they 4 <br /> Number of living units: _L: Numbei of_bed. ms <br /> Character of soil to,a depth of 3 feet: - Water table depth <br /> SEPTIC TANK: Type/Mfg }Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ( ��! Method of.Disposal I <br /> Distance to nearesf: Well f Foundation _ Property <br /> LEACHING LINE Cl No. & Length of lines i ,r Total length/size <br /> FILTER BED _ HCl m Distance to nearest: Well Founds on `Pperty rL ne <br /> SEEPAGE PITS 'I I Depth x Size _ �. Numb9r <br /> SUMPS Lt Distancetonearesto—WiN "'y"Foundation' � Property Line I <br /> 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 San Joaquin County <br /> Home owner or licensed agent's signature certifies the following:•"I certify tharin 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 wo'rkman'a compen'sation'Iaws of California." Contractor's 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 compen,sa i <br /> tion laws of California." i y �,i <br /> The applicant call fora e ired nspections. Complete drawing on.reverse siVC <br /> c , '-4. - <br /> sSigned --Title: - _ ._ Date: J r ' <br /> , + s <br /> , ! <br /> FOR DEPARTMENT-USE ONLY . . <br /> Application Accepted.by Date f 2 Area <br /> Pit or Grout Inapection by Date Final Inspection by 1 Date <br /> '+t Additional Comments: <br /> App icant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> ii .445-N San Joaquin, P 0 Box 2009, Stkn, CA 95201 ; <br /> FEE i <br /> + INFO. _ AMOUNT DUE AMOUNT REMITTED CK REGTIVED BY ATE + PERMIT'N0. <br /> FH 114.2E IREV.r,h a+ 15R l"1 �/ 8 a � <br />