Laserfiche WebLink
APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> . 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT Eg- TRES 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 an the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address -I r� f City Lot Size/Acreage <br /> Owner's Name �j �l <br /> / Phone CJ S� <br /> Contractor <br /> ddress 3/0 <br /> License No. one <br /> TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPi_ACEMENT DESTRUCTION ❑ t of Service Weil ❑ <br /> f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ INonitoring well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD> 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 <br /> Dia. of Well Casing - <br /> C-1 Domestic/Private ❑ Gravel. Pack_ i ❑ Tracy Type of Casing_ r. q <br /> A <br /> Specifications �+ <br /> 1'} Public 1-1 Other E Cl Delta Depth of Grout Seal r <br /> t I Irrigation Type of Grout <br /> Approx. pepthk I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done 9 <br /> _ <br /> Well Destruction' ❑ Wel.Diameter I Sealing Material & Depth <br /> De*'. Filler IKaterial Depth <br /> >T.YPE OF SEPTIC WORK: NEW INSTALLATIlON I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial available within 200 }set.) <br /> 0 ier <br /> f Number of living units, Number of bedrooms t <br /> Character of soil to a depth 04-3-feet:- <br /> SEPTIC TANK. Water table depth <br /> ❑ Type/Mfg <br /> PKG. TREATMENT PLT, ❑ Capacity No. Compartments <br /> " - D <br /> ¢� Method of D' osal <br /> Distance to nearest: Wolf 4 11 FoundetioA---L.= q_ Property Line <br /> LEACHING LINE C1 No.-& Length of lineT¢s Etai length/size <br /> , <br /> FILTER BED nDistance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth i Size <br /> f4umber <br /> SUMPS <br /> 0 Distance to nearest: Well Foundation <br /> DISPOSAL PONDS p i Property Lina <br /> I hereby certify that I have prepared this application and that the-work will be done in accordahce with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joa`quin'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 compenss <br /> tionlawa of California." <br /> The applica at for requ' ed ins tions. Camp a ing on re rse side. <br /> Signed <br /> Title: Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by C Date i'3 <br /> Area 02 <br /> Pit or Grout Inspection by Date Final Inspection by <br /> '" Date3 <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 0 Box 2009, stkn, CA 95201 <br /> FEE AMOUNT Ot1E AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE <br /> ;;7EN 1!-IeEH 13-24 IAEV.rHal cy `J <br />