Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN,, PHONE (209)468-3420 <br /> .�y P 0 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 described. This <br /> application 1s made in compliance 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 rrilkal 4 %+JCity Er eine/Acreage <br /> Owner's NameVAs dt4 5s�+r Aaa r AJ vcleI �--�e Phone <br /> Contractvr <br /> .ZJ� (�` 7 l l w. Address Q 1�] cense No. Phone p �� <br /> TY-PE OF WELL/PUMP: NEW WELL ❑ / WELL REPLACEMENT Fvve DESTRUCTION Wout of Service Well Ll <br /> PUMP INSTALLAT'IOONN, '� SYSTEM REPAIR OTHER ❑ Monitoring Well �3 <br /> .DISTANCE TO NEAREST: SEPTIC TANK �SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 41Z <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS : <br /> [�mesIndustrial ElO n Bottom © Manteca Dia. of Well Excavattiooi Dia. of Well Casing r <br /> ticlPrivate C!!'Gravei Pack ❑ Tracy Type of Casing_ P 4c, -_ Specifications <br /> +l'1 P blic 1-1 Other n Delta Depth of Grout Seal _ �, Type f Grou <br /> �f�{fation A<P� prox. Depth I I�E_asternrfaCe Seal Installed by <br /> Repair Work Done t� Type of Pump ! H.P. State Work D n _ O <br /> Well Destruction Er' Well Diameter Sealing Material to Depth <br /> Depth I3 D Filler Material b Depth f _ .64.0 r L l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1,1 REPAIR/ADDITION I 1 DESTRUCTION I i (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installittion will serve:- Residence_ Commercial Other - I <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> "SEPTIC TANK ❑ , Type/Mfg Capacity No. Compartments ' <br /> r <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well ��O�union Property Line - -� <br /> 77 <br /> LEACHING LINE 0 No. & Length of linesTotal length/size <br /> FILTER BED 0 Distance to neatest:- ell Foundation Property Line -� <br /> SEEPAGE PITS 11 Depth Size Numb <br /> SUMPS LI Distance to nearest: Well Foundation Pro rty Line c <br /> DISPOSAL PONDS Q .4 <br /> I"lsareby 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 anyperson ' c ner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fol ing: "I certif that in the performanc the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of alifornia." <br /> The appli ant ust I requ" d ' omp wing on r e side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY s - <br /> Application Accepted by ea <br /> Pit or G out nspection by Date Final Inspection by Date <br /> Additional Comments: <br /> �. S <br /> Applicant - Return 11 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 INFO !AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. <br /> EH 13-24 IREV. <br /> EH 11.2E j rr <br />