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 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 Ho. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County lPublic Health Services. /�� �{ <br /> Job Address 11 112�k e ] ['1L�.J@CI w City Lt� Lot Size/Acreage <br /> Owner's Name d K Address LLL'1 a1 /c ke_V(29411(f Phone 7 <br /> r <br /> / <br /> Contractoru-11 J t h Address � ense Nov"-C?9-3$ Phone-]CC''T`o' �7 <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT DESTRUCTION°.QLDut of Service Well ❑ <br /> PUMP INSTALLATIONX SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well E7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE iEQ <br /> FOUNDATION AGRICULTURE WELL none- OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT)ONS_ :. <br /> L-1 Industrial 59Open Bottom O Manteca Dia. of Well Excavati Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ ti Dia. <br /> I Specifications <br /> 1') Public Cl Othpr ❑ Delta Depth of Grout Seal0 Typa_ot rout_ <br /> i I Irrigation c9aQApprox. Depth I I Eastern Surface Sedl installed by A I I M <br /> Repair Work Done L3 Type of Pump �� H.P. r State Wo Done _ <br /> .�-. <br /> Well Destruction Well Diameter _ Sealing Material & Depth D'A- U <br /> Depth S1 Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION I I {No septic system permitted if public sewer is <br /> available within 200 feet.l <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 r <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line {� <br /> SEEPAGE PITS 11 Depth Size Number <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 re uired inspections. Cpmplete drawing on reverse side, <br /> Signed Title: E' re e- - Date: VA Q <br /> FO EPABTTMENT USE ONLY <br /> Application Accepted by (% Date L Area p <br /> Pit or Grout inspection by Date �a nal Inspection by �' Date o <br /> Additional Comments: IVomlyt <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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'ND. <br /> EH 14.26IAEY, Ai­r,o t Q t 00 lQ 3 $ $ 7V 1-92, `�Z /'� <br />