Laserfiche WebLink
SAN JOAQUIN COUNTY ,PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL-,HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> y� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I1' <br /> (Complete in Triplicate) <br /> Application 1hereby 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 /> Job Address E Lw City n� Lot Size/Acreage <br /> .;1. <br /> `fy / �cl­l LN- --6&- Phone <br /> 4 Owner's NamelD �� _` p G.A-C-t�l4ddress v <br /> if �� _ �Contractor Address t�� � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D Out of Service well ❑ <br /> ' PUMP INSTALLATION 12qSYSTEM REPAIR C1OTHER p Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL-FLD, PROP. LINE_ <br /> IM FOUNDATION AGRICULTURE WELL OTHER WELL - M <br /> PITS/SUPS <br /> INTENDED USE TYPE OF WELL PROB'LEM'A-REA CONSTRUCTION SPECIFICATIONS <br /> C-1 Industrial 1 ❑ Open Bottom ❑ Manteca Dia, of Wail Excavation --- -- Dia. of Well Casing <br /> iSd.Domestic/Pri ate Ll Gravel Pack ❑ Tracy Type of Casing_ Specifications - <br /> i'l Public 1-1 Other 11 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth l I Eastern Su ace Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> of Sealing Sealing Material & Depth <br /> f Well Destruction�I d © Well Diameter <br /> Depth Filler Material & Depth \ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITtON I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.l <br /> C <br /> Installation will serve: Residence�.... Commercial_ Other � <br /> Number of living units: Number of bedrooms <br /> Character of Boil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK IM ❑ Type/Mfg Capacity -No. Compartments T 1 <br /> PKG. TREATMENT,PL-T..CI � ';� Method of Disposal � <br /> Distance to nearest: Well Foundation Property Line <br /> 4 <br /> LEACHING LINE D No. & Length of lines - Total lengthisize <br /> FILTER BED I�. ❑ Distance to nearest: Well - J Foundation Property Line <br /> SEEPAGE PITSr i 'I.I Depth Size i _ Number s <br /> SUMPS :l LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ r.. <br /> i <br /> I hereby certify that I have prepared INS. application and that he 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 cokifes 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 m <br /> becoe,subjict'to workman's compensation laws of Cafifornia." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of theworkfor which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of C a. <br /> 1 The ant must I for all required ins tions. Co plate drawing on reverse side, <br /> Signed X Ir Title: L2c __ Date: O �- <br /> FOR DEPARTMENT USE ONLY op <br /> f Application Acce`pted-by-F- ` fweA facer _—_ Date 2 l7 Area Z1 <br /> Pit or Grout tns ll5ection by Hate Final Inspection by - Date <br /> t <br /> Additional Commants: <br /> t Applic,ant!` - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> r 445 N San Joaquin,•P 0 Box 2009, Stkn, CA 95201 t <br /> FEE AMOUNT DUE AMOUNT REMITTED CKO CASH RECEIVED BY DATE PERMIT N0. <br /> iRFO <br /> . £H13-2A IRev.1iN5 <br /> EH 14•20 <br /> :i <br />