Laserfiche WebLink
SAN _AQUIN COUNTY PUBLIC HEALTH 3VICES <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 descr bed. This <br /> application is made In compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sar, <br /> Joaquin County Public Health Services. ,/ n t <br /> )(Job Address 51 r / �* c City�'�„� ��1'y� Lot Size/Acreage <br /> Owner's Name I'fitwG4 <br /> /\ Address . �' ' /Phone <br /> 1OnlractorS A4I-jP-CC('_ Address "o _&x 4/ i License No.�Z Q, / Phone-3V <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ _ SYSTEMREPAI OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SE LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICUL LL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM CONS UC�TION SPECIFICATIONS <br /> f] Industrial ❑ Open Bottom ❑ eca Dia. of Well Exca�atlo=` Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack „/�Tracy Type of Casing_ Specifications \, <br /> I'1 Public F] Other_- ! n Delta Depth of Grout Seal Type of Grout Q <br /> I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of b <br /> Character of soil to a depth of 3 feet: ... Water table depth <br /> SEPTIC TANK ❑ Type/Mfgt)(fD_h_AV11No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1JBrmIt Method of Disposal <br /> Distance to neareViork We, <br /> ell �° PP W'p Property Line <br /> VV�t <br /> g �r IhCn gtp1 ngth/size <br /> LEACHING LINE ❑ No. & Len Length of li �', ti..t. eL �JJ <br /> I <br /> FILTER BED CI Distance to nearest: Well akj r�, Property Line <br /> 1 r.7,1 M <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS 1-1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 which this permit is issued, I shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant ust call f rr�a11 req ired inspections. Complete drawing on reverse side. <br /> 1lData: <br /> �C TMENT USE ONLY <br /> n '] p Q / <br /> Application Accepted by ��X(� AA �lfJy trn,' Date /— l ` Z- Area ` I <br /> c <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO /�- CASH <br /> • EH[31(REV.rinsr [[[EH1S � © q (L g Z 1 436 <br />