Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' <br /> 141 '�'� ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 tvD <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) k*Q �o,� , . , <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 /> �rnr�.� City Lot Size/Acreage <br /> Job Address .C_L—�— <br /> Address ---�-�� Phone <br /> Owner's Name `` <br /> Contractor dress <br /> License NoG�3 3�Phone <br /> TYPE OF WEL / UMP: NEW LL ❑ WELL REPLA EMENT DESTRUCTION ❑ Out Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O <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 'y\ <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _— Dia. of Well Casing <br /> 1.1 Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications (� <br /> I'l Public 1.1 Other n Delta Depth of Grout Seat Type of Grout v` <br /> I Irrigation Approx. Depth t I Eastern Surface Soul Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Sealing Material & Depth <br /> Well Destruction Well Diameter <br /> Filler Material & Depth <br /> Dep At <br /> TYPE OF SEPTIC WORK: NEW INST ION I ) REPAIR/ADDITION I I DESTRUCTIOfjt (No septic system permitted if 1 lic 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: r 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 at length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distanc Barest: Well Foundation Property Lin <br /> DISPOSAL PONDS ❑ ' <br /> 1 hereby certify that I ha a 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 m st or quir d i ape, ions. Compl to r ` Ing on r side. <br /> Signed X <br /> Title: Date: <br /> F�IDIEPA�IRIT�MEN�TIUSE ONLY <br /> Application Accepted by Date 2 Z Area b <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> A� <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 95201 <br /> FEE AMOUNT DUE AMOUN REMITTED C H ECEIVED BY DA PERMIT'N0. / <br /> . EH 13.26 IRINFOEV.rixsr cQ <br /> EH 14•26st) -' <br /> �� <br />