Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 N01ty <br /> P 0 BOX 2009, STOCKTON, CA 95201 CK p <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �w <br /> (Complete .in Triplicate) <br /> Application is hereby made to Sen Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in coneliance with San Joaquin County Ordinance No. 549 and 1862 and the 'Rules and Regulations of San J <br /> Joaquin County Public Health Service <br /> City Lot Size/Acreage <br /> Job Address <br /> e <br /> r <br /> Owner's Name I� _ Address � � Phonet/ 2 - 6 <br /> � t <br /> Contractor <br /> TYPE OF WELL/PUMP: I� NEW WELL 0 WELL R LACEMENT C7 DESTRUCTION_0 Out of Service We11 <br /> PUMP INSTALLATION ❑ Y111A REPAIR OTHER Q <br /> Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINDISPOSAL FLD. PROP. LINE <br /> _ FOUNDATION AGRICULTOTHER WELL PITS/SUMPS <br /> INTENDED USE STYPE OF WELL PROBLEM AREA CTI SPECIFICATIONS <br /> pia. of Well Casin Industrial E'. O 0n Bottom © Manteca xcavation 9{ <br /> f.) Domestic/Private 0 Gravel Pack 0 Tracy i 9 SpecificationsI'1 Public Ia Other �l Delta ro tSeal Type of Grout1 i <br /> I I Irrigation —;�pprox. Depth I I Eastern ul I stalled by <br /> c Repair Work Done, 0 Type:�of Pump H:P..__ --- t State Work Done <br /> Well Destruction-) 0 Welt'Diameter Sealing Material & Depth `l <br /> ,t1 .> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> I ; avails le within 20@ feet.) <br /> Installation will serve: Residence_ Commercial— ,Other <br /> Number of living Unita: �M Number of bedrooms - l <br /> Character ob sail to a depth of 3 feet: <br /> r Water,table depth <br /> SEPTIC TANK '~ 0 ; Type/Mfg Capar�ty No`Cornpartments ` <br /> PKG. TREATMENTPLT. CI I� lulethod of Disposal <br /> + r Distance to nearest: Well Foundation �,�+ Property Line - (� <br /> ,,.,LEACHING LINE Cl Nho, & Length of linea -" Total length/size i <br /> FILTER BED n # Distance to nearest: ,Well �r ndation Property Line <br /> SEEPAGE PITS- (I, Depth` Size Number <br /> SUMPS El Distance to nearest: . Well F undation Property Line <br /> DISPOSAL PONDS 0 I 1`, <br /> I hereby certify that I have prop <br /> this application and that the ork 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 shell 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 /> M certifies the following: "I certifyiklthat 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." ! ill, ` <br /> The'applican ust call f required spections. Complete drawing on reverse side. <br /> Fr <br /> ! Signed X s _I� - Title: Date: . m <br /> F DEPARTMENT USE ONLY t <br /> Z ^Z <br /> Date Area { <br /> Application Accepted by <br /> �Y <br /> k Pit or Grout Inspection by Date Final Inspection try Date <br /> Additional Comments: 999. <br /> I�I - <br /> Applicant - Return all copies to: San Joaquin County Public Health Services. — <br /> Environmental Health permit/Services <br /> �L 445 N San Joaquin, P O Box 2009, Stkn, &A 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY 't)ATE ; PERMi7'NO. <br /> INFO CASH <br /> + Ell 13-24 IREV.r/K 5f <br /> EFS 11-26 o <br />