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 /> R <br /> PERMIT EXPIRES 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 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address ` Oso City S� Lot Size/Acreage <br /> Y <br /> Owner's Name Address Sc. Phone <br /> Contractor c-- Address License Nal ©C/4 Phon2 a. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION Ll Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR%R:- OTHER ❑ Monitoring Well G7 <br /> I <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 /> F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i <br /> ?"omestic/Private ❑ Gravel Pack7 L] Tracy Type of Casing_ Specifications <br /> I"I Public (-3 Other , ❑ Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation —.Approx. Dep I Eastern Surface Seal Installed by <br /> Repair Work Done X Type of Pump H.P. -14- State Work Done Pl;�_ I <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth r <br /> Depth Filler Material & Depth {� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I 1 INo septic system permitted if public sewer is \� <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/sire <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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: "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 i <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 <br /> The w scant mus all for all required ' spe.ctions. C plate drawing on to se s�isde. <br /> Signed Title: / _ Date: <br /> 91/P.:;i, <br /> i <br /> OR EPARTMENT USE ONLY <br /> Application Accepted by Zl� Date A a24 <br /> 2-1 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N Sap Joaquin, P 0 Boz 2009, Stkn, CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. ' <br /> Ihlypq CASH <br /> . EH 00 <br /> 13-14IAEV.t�xsi 11 _ y♦ <br /> CH 1{•m ii <br />