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 /> 1 <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUID <br /> (Complete in Triplicate) <br /> Thid. <br /> Application is hereby mede.to San Joaquin County for a permit to construct and/or 1 install the Work herein illations of San <br /> 6 <br /> application is made in compliance with Ban Joaquin County Ordinance No. 51+9 and 1862 end the Rules mail Rego <br /> Joaquin County Public Health Services. �� F <br /> Lot Size/Acreage <br /> City _ R <br /> Job Address f <br /> A. <br /> GG� � , '�� 9�� Phone 4 <br /> Address a , <br /> Owner's Named Ezd�� License No• � Phone <br /> Gonirac ori ^ddress G <br /> NEW WELL I WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well L <br /> TYPE OF WELL/PUMP: OTHER Monitoring Well �� <br /> PUMP INSTALLATION ® SYSTEM REPAIR ❑ <br /> SEWER LINES �.--- DISPOSAL FLD. PROP. UNE <br /> DISTANCE TO NEAREST: SEPTIC TANK 1_ <br /> FOUNDATION PITS/SUMPS <br /> 1 AGRICULTURE WELL OTHER WELL <br /> ..� <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS +r <br /> INTENDED USE ------ _ ,_ Dia. of Well Casing fl <br /> 9 Open Bottom ❑ Manteca Dia. of Well Excavation��— +i3 �J <br /> n industrial .�_ Specifications <br /> Type of Casing_.— <br /> X Domestic/Private 0 Gravel Pack C7 Tracy Depth of Grout Seal � �S10� Type of Grout <br /> I:1 Other �1 Delta 1 <br /> 1'1 Public Surface Seal Installed by �} <br /> I I Irrigation _3� AiV4ApProx. Depth 1 1 Eastern <br /> H.P. <br /> State Work.Done, <br /> Repair Work Done [� Type of Pump ' -- Sealing Material 6 Depth <br /> Well Destruction ❑ Well Diameter i Filler Material 6 Depth <br /> Depth <br />€ TYPE 01` SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION 1 1 available+wi within 200 feet,c system per ) if public rawer +s <br /> Installation will serve: Residence Commercial^ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet:' No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg I Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line �— <br /> Distance to'nearest: Well Foundation <br /> If Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED n Distance to nearest: Well Foundation -- <br /> SEEPAGE PITS 11 Depth Size <br /> r' Number <br /> SUMPS Ll Distance to nearest: Well <br /> Founition Property Line -- <br /> DISPOSAL PONDS ❑ <br /> I hereby canify that I have prepared this application and that the wok will be done in accordance with San Joaquin county ordinances, state laws, an <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 his permit is issued, I signa <br /> shall not <br /> ." Contractor's hiring of <br /> ation laws of California <br /> emply any the following:&uch I certify <br /> that n the perfnner as to ormance of othe wok lot which this permit is issued, I shall employ persons subject to workman'scompensa <br /> certifies <br /> tion laws of California." ` <br /> ` The applicall for-all r uir d pections. Complete•drawing on everse SL <br /> Title: <br /> Date: <br /> Signed X. <br /> FOR DEPARTM NT USE ONLY <br /> Date Area <br /> Application Accepted by L <br /> ut <br /> 3 Y Final Inspection by Data <br /> Pit rospection b - ate -- <br /> Additional Comments: <br /> -a�Eo Cc. •yrs--�. a <br /> blic Health <br /> + Applicant - Return all copies to: Ean Joaquin nvironmentaloHealthuntY uPerrnit/Servicesvices <br /> E 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> Ei CK RECEIVED BY DATE PERMIT NO. <br /> ll FEE AMOUNT DUE AMOUNT REMITTED ASN 0 <br /> 3 z 4 - A . <br /> . EK 13•24(REV,1/H 51 • <br /> (:H 14.75 <br />