Laserfiche WebLink
r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> i P O BOX 2009, STOCKTON, CA 95201 <br /> I 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 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 Services. <br /> I Cit i reage <br /> Job Address <br /> Q `] 1s, - Phoneq� <br /> { rass ��— <br /> w er's Name I _Sk,3__ <br /> r <br /> ` "WV s (cense No._49HPhone <br /> t Co actor <br /> ' TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENY 11 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION D <br /> SYSTEM REPAI OTHER d Monitoring Well (3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> gC1 striai ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing <br /> estic/Private , 0 Gravel Pack C1Tracy Type of Casing_ Specifications <br /> II Public C7 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation t1. Approx. Depth IEastern Surface Seal Installed by <br /> Repair Work Done v 'Type of Pump H P. ' State Work Don <br /> M Well Destruction �❑ Well Diameter <br /> t Sealing Material & Depth' <br /> Depth Filler Material 8 Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDiTION I I DESTRUCTION I I fNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> I Installation will serve: Residence— Commercial— Other <br /> i <br /> Number of living units: 't Number of bedrooms I <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑t Types/Mfg Capacity ? ' No. Compartments <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> % 1 <br /> LEACHING LINE L"1 Na\ A Length of lines l Total length/size <br /> ti <br /> FILTER BED ❑ Distance to nearest: Wel{ Foundation I Property Line {� <br /> SEEPAGE PITS I I Depth r 2'' Size = Number <br /> I <br /> SUMPS Ll Distance to niarest: Well Foundation — Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared thislappfication 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 performece of the work for which this permit is issued, I shall not <br /> mploy 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 i6 ued,!I shall employ persons subject to workman's compensa- <br /> tion laws of California." _y -*,- • ! I <br /> The applic ust callIL00811 required inspections. Complete drawing on'r verse.side. } r <br /> i <br /> Signe Title: Date: <br /> I <br /> 1 DEPARTMENT USE ONLY <br /> Application Accepted by ODate, <br /> l Dattyi�e� <br /> Pit or Grout Inspection by Date Final inspection by <br /> L�iz� <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 /> CKSFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT'NO. <br /> INFO / �ftJ <br /> } EH 13-24(REV.r i w si `� %J/ <br /> EH 14.2E C/ `y . <br /> YR <br />