Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> tom. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-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 /> i 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. �, 1 <br /> Job Address T ,,,/.�!,00'se,„ ,_____,._ __..... Cit�C`lI61 T"b L Size/Acreage <br /> Owner's Name -CAliS_S Address , ([��� Phone <br /> Contractoress�r0R©`be— N2.7 License No.r h'2173 Phone +D <br /> TYPE OF WELL/PUMP'. NEW WELL El WELL REPLACEMENT C7 DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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 /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Ea Domestic/Private C! Gravel Pack L] Tracy Type of Casing_ Specifications <br /> V1 Public 1-1 Other n Delta Depth of Grout Seal Type o rout <br /> I I Irrigation -/ Approx. Depth 11 stern S rface Seal Installed by 2� <br /> Repair Work Done O Type of Pump H.P. __ ! State Wo*D0 <br /> Welt Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is. i <br /> available within 200 feel.! l ^ <br /> Installation will serve: Residence mercial— Other <br /> Number of living units: N idrooms 1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg to. y No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well 'y fou bion?: r �! Property Line r <br /> r ' <br /> LEACHING LINE ❑ No. & Length of lines A. otal Length/size y <br /> FILTER BED ❑ Distance to nearest: 11 Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number # <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby cenify that f 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 lic is 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 per n in such me nor as to become subject workmen's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the owing: "f cartif that in the ormsn of a work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws Callfor a." <br /> The appli ant all r d ' om e-en e sii <br /> Signed Title: Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date — Area <br /> Pit or Grout Inspection by Data 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 San Joaquin, P O Box 2009, Stkn, CA 95201FEE <br /> K 9 <br /> INFO AMOUNT DUE AMOUNT REMITTED /�AA`SI, RECE�I^VED BY DATE PERMIT'NO. <br /> . EH 113.24{REV. 5) <br /> ADO <br /> i{•2a J1— <br /> EH rr I.7 <br />