Laserfiche WebLink
f II <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> I , 445 N SAN JOAQUIN, PHONE {209}468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> r <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 1 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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Ser <br /> Job Address -7 ' v c s. P City I Lot Size/Acreage <br /> T (� ° <br /> 4- Owner's Name. � Address Phone <br /> jar Fs r a �1 � d l'.F ,,.,, ,;j 1 �I� •-7 C ! S �U-� <br /> Contract Address �i G "`' I License No. P, roc �'?l�Phone hV <br /> T1YiPE OFIWELLLPUMP:—� NEW WELL ❑ WELL REPLACEMENT R DESTRUCTION ❑ Out of service�Nell Cl <br /> I n 'PUMP INSTALLATION O SYSTEM REPAIR`❑ OTHER Q Monitoring Nell ❑ <br /> . - ,s <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE j <br /> FOUNDATION AGRICULTURE WELL OTHER WELL—.PITS/SUMPS.—: � <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I In Industrial C3 Open Bottom C1Manteca Dia. of Wail Excavation Dia. of Well Casing <br /> tri <br /> f 1 <br /> Domestic/Private ❑ Graver Pack ❑ Tracy Type of Casing_. Specifications f' <br /> I'f Public 1.1 Other Cl Delta i 1­0 epthof,Grout Seal Type of Grout <br /> I I Inigation —..App(ox, Depth l I Eastern i Surface Sed1 Installed by <br /> Repair Work Done L7 Uy-ofFPump H.P: State Work Done <br /> Sealing"-Material & Depth �] <br /> Well Destruction D WelI Diakhetera, - e 1 . <br /> Depth il"'yi -¢_ Filler,Materieil L Depth <br /> TYPE OF SEPTIC,WORK: NEW INSTALLATION I I REPAIR. DDITIOM —DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> i 1 � available within 200 feet.) I, <br /> Installation-wilI serve*•.;Residence K Commercial - Other_ f <br /> r Number of living units: h-dNumber of idrooms <br /> Character of soil to a depth-ot�3rfeet:, Water table depth <br /> I SEPTIC TANK., --13- Type/Mfg p� A W $Capacity - -No.Compartments <br /> PKG. TREATMENT PLT: Cl �. Y ti �', Method of Disposal <br /> D'+stance to nearest: Well Fouit+fatioh `, -' Property Line <br /> t LEACHING LINE 0 No. & Length of.;lines � Tdtaf length/size r <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ' 1 1 Depth {'r Size. X r d 1 lumberIt <br /> I SUMPS Distance to nearest: Well Fountlation�— Property Line _ _ <br /> DISPOSAL PONDS C) !I 1 - r <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 la s, an <br /> rules and regulation`s of the Sen Joaquin County ' ' 1 <br /> Home owner or liaansed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I sha11 t <br /> employ any person in-such manner as to become subject to workmen's compensation laws of California."Contractors hiring or sub-contracting signature <br /> i certifies the foll6wing: "I certify that in the performance of the work for which thii permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Califor'la." <br /> The applicant call for quir d inspections. Complete drawing on reverse ids. u <br /> Signed K Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> r Appl' ion Acceptgd by .r� Date 2—. Area L � <br /> ttHor rout Inspection by t Datef:36&!EJ- Final Inspection by Date� - <br /> Additional Comments: I <br /> :i <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> II Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEEAMOUNT DUE AMOU REMITTED C S ECEIVE BY TE PERMIT NO. <br /> INFO - <br /> . EH13.24{REV.i/nit <br /> EH 14.2E <br />