Laserfiche WebLink
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 EXPIRES 1 YEAR FROM DATE ISSUID <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. /q <br /> 1 <br /> Job Address Lot Size/Acreage <br /> � tt a C�� � <br /> Owner's Name C^ NA� Address DA/ Phone .J! a <br /> I ll Address �^ License No. Phone <br /> Contractor S� of service W <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT n DESTRUCTION ❑ out Monitoring Well ❑ <br /> PUMP WSTALLATLON ❑ SYSTEM REPAIR ❑ OTHER ❑ <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 /> Cl Industrial ElOpen Bottom 0 Manteca Dia, of Well Excavation Dia. of Well Casing <br /> C.l Domestic/Private Cl Gravel Pack n Tracy Type of Casing_ Specifications <br /> Cl Public I-) Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I i Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> & <br /> Well Destruction C:) Well Material Well Diameter � -Depth <br /> Depth Filler Material d Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION DESTRUCTION l I (No septic system permitted if public sewer is l� <br /> available within 200 feat.I <br /> Installation will serve: Residence-)�­ Commercial_ Other <br /> Number of living units: -A— Number of bedrooms - <br /> Character of soil to a depth of 3 feet: Water table depth V d <br /> SEPTIC TANK ❑ Type/Mfg _�Q r'4 — Capacity m 6 No. Compartments <br /> Disputa <br /> PKG. TREATMENT PLT. C7 r Method of Disposal <br /> Distance to nearest: Well ,06Foundation _ Property Line <br /> �7 <br /> LEACHING LINE No. & Length of line Total length/size <br /> FILTER BED ❑ Distance to nearest: Wel Property Line_ <br /> 410i I DO <br /> SEEPAGE PITS Depth 1A: Size N mbar <br /> SUMPS LI 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 must call for all required inspections. Complete drawing on reverse side. �. <br /> y`Z ned X.d. Title: Date: <br /> g <br /> FOR DEPARTMENT USE ONLY flfl <br /> dii, <br /> AppliAccepted by < Date V off--- Ares <br /> or Grout Inspection by Date��� Final Inspection by/ r <br /> Additional Comments: <br /> Applicant - Return aj c iRp es : San Joaq in County Public Health Services <br /> �jJ a� (KJJ�6� Environmental Health Permit/Services <br /> 'l-! 3' / 2 44 N San Jo P O Box 2009, Stkn, C 95 �� r <br /> w r i/'c� rL� 2 _ <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM T'N0. <br /> INFO <br /> . EH 3-24(REV. 51 !f �0 /1� 410 /� ? <br /> fN 5426 <br />