Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t <br /> ENVIRONMENTAL HEALTH DIVISION t <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> C <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 I' <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. p� <br /> �ij3 "�,�Q�J� ar City �Lot Size/Acreage <br /> Job Address � ,� - <br /> a <br /> rOwner's Nam .�3�I �6 <br /> I t S Address -� Phone <br /> +\ <br /> Contractor <br /> �S �r r ZbrGAddressaLicense Nr� 7,,S' _Phon <br /> TYPE Of WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Fi Out of Service Well Cl <br /> PUMP INSTALLATION ❑ r SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK.I -- SEWER LINES ega!? ___ DISPOSAL FLD. PROP. LINE <br /> FOUNDATIONAGRICULTURE WELL,! S OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation .z z Dia. of Well Casing <br /> ns <br /> Z f Do'omestic/Private , Gravei Pack .i ❑ Tracy Type of Casing_ G z 1 Specilic Grou <br /> I'l Public (:1 Ojher 31"4nt fl Delta Depth of Grout Ssal Type of Grout <br /> C410 <br /> I ; Irrigation ,302!Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction D Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION ! I DESTRUCTION I I (No septic system permitted if public sewer is <br /> i 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 D No. & Length of lines Total length/size <br /> t <br /> FILTER BED n Distance tolnearest: Well Foundation Property Line <br /> SEEPAGE PITS I [ Depth f Size Number <br /> SUMPS Cl Distance to'naarest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ,I <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, an <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent'ssignature 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." I <br /> The applicant ust call for all required inspections. Complete drawing on reverse side. <br /> �. �/J r f <br /> Signed X /e. � �T.��f� __ Title: De`tIleY+ - . _-- Date: •`�6�� <br /> i <br /> FOR DEPARTMENT USE ONLY ii a <br /> Application Accepted by Date C�( l��2� .__ Area &Z <br /> Pito Grout apection by AyeDate Final Inspection by Date <br /> s <br /> Additional Comments: `" I <br /> Applicant - Return all copies"to: San Joaquin County Public Health se ices <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> ti <br /> EH 14-76 � 1 <br /> s <br /> J <br />