Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ! <br /> ' ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> I P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUID <br /> !1 (Complete in Triplicate:) <br /> Application is hereby made to San Jpaquia 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 end Regulations of San <br /> Joaquin County Public Health Services. / <br /> L Q City Lot Size/Acreage <br /> Job Address f <br /> �r 4 Address � 1 �Phone <br /> Owner's Name • ° <br /> CaG 1 f/ Q'u t L?�5���, Phone 17 <br /> Contractor Address License No _� <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL,REPLACEMENT n DESTRUCTION ❑ Out of Service Well L1 <br /> OTHER O Monitoring Well C7 <br /> PUMP INSTALLATION [a' SYSTEM REPAIR L <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLO. PROP. LINE <br /> FOUNDATION- AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> ti <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ; <br /> f] Industria! 0 Open Bottom D Manteca Dia. of Well Excavation I <br /> Type of Casing- Specifications <br /> f. g <br /> 606 estic/Private ❑ Gravel Pack ❑ Tracy T Type of Grout <br /> ['i Public [:1 Other i-1 Delta Depth of Grout Seal <br /> I I Irrigation __-._ Surface Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump 1 WP. State Work Dome _ <br /> E Sealing Material & Depth <br /> Weil Destruction ❑ Well Diameter � -^ i <br /> Depth r Filler Material aDepth - <br /> c system permi <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I alvailablerwithin 200 feettled if public sewer is <br /> Installation will serve: Residence iCommercial_ Other _ <br /> Number of living units: Number of bedrooms S <br /> 3 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> , <br /> SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments <br /> PKG, TREATMENT PLT. Cf. rl Method at Disposal <br /> � r <br /> Distance to nearest: Well Foundation Property Line <br /> I I — <br /> LEACHING LINE ❑ No. & Length of lines t Total length/size <br /> FILTER BED D Distance tot Barest: Well i Foundation Property Line <br /> SEEPAGE PITS 11 Depth 'r Size Number <br /> Distance to Well Foundation Property Line <br /> SUMPS LI Dista . <br /> DISPOSAL PONDS a ' <br /> I 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: "l 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 workmen'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 applican ust call for all required inspections Complete drawing on r rsa de. <br /> Signed Title: Date: ..� <br /> FOR DEPARTMENT USE ONLY l � q f <br /> Date rsa <br /> `~ r3 • <br /> Application Accepted by <br /> Pit or Grout Inspection by Date { Final Inspection b Date <br /> t <br /> Additional Comments: F <br /> 1 t <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 DUE ''�' AWITTED SH RECEIVED BY DATE PERMIT N0. <br /> INFO C ry <br /> k + tj <br /> EH 13-24lREV.I/K5) ©� Q <br /> IEH 14.26 <br /> i <br /> i <br /> i ' <br />