Laserfiche WebLink
_ Li.CrL1%.,ZI11WAN <br /> . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 0,)O��445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> 361` PO BOX 2009; STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r ; r r ; y z ; (;C.omplete tia,Tkiplicate) <br /> Applicationis hereby made.to San Joaquin County for a permit to construct and/or install.the work herein described. This <br /> 4pi"batlbn to cantle In ooetplianee with San Joaquin County Ordinance No. 549 and 1862 and the Rules and RopuaAtiona or elan <br /> Joaquin County Public Neaith Bery ees. t <br /> -Job Address Z�� /iT/[/��i J f/L//�� of Size/Acreage 3 <br /> Owner'sName !E _ -)Address -��-' t✓� Phone 7 <br /> L& <br /> t o ` se No. k&��hone / _ <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT O DESTRUCT16k 0., t of Service Well <br /> PUMP INSTALLA,TI��O,,� SYSTEM REPAIR n OTHER Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK ,L1'=i�1L— SEWER LINES DISPOSAL FLD. PROP. LINE/ <br /> FOUNDATION AGRICULTURE WELL' OTHER WELL PITf2/9WfVIPg `�� <br /> INTENDED USE PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial pen Bottom ❑ Manteca Dia: of Well Excavation Dia. of Well Casin <br /> 11 Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ ! Specifications <br /> I'1 .ublic Cl Other fl Delta Depth of Grout Seal Type of- I <br /> igation _.Approx. Depth I I Eastern Surface Saul Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material 6 Depthr //�,Q„_. _`(L ��Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public r <br /> available within 200 feet.) <br /> Installation Will serve: Residence_ Commercial Other <br /> Number of jiving units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O: Type/Mfg Capacity- No. Compartments <br /> PKG. TREATMENT PLT. Cl <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. 6 Length of lines Total length/size <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size — Number <br /> SUMPS Ll Distance to nearest:' t` Well Foundation __ Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application gnd 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 workmen's compensation laws of Califon *a 11 Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify th the pert the work for Which this permit is issued hall employp�rsons ubject to workman's compensa <br /> tion laws of California.' / Ly�`r�,�Y <br /> The applic Mgt ca N s cti s. C Ibte ElSwing on rover side. / <br /> Sigr: dA <br /> Title: Date. <br /> FOR DEPARTMENT USE ONLY C <br /> Application Accepted by bate �' �-3`Q 17nZ� Area d I <br /> \ u /rI� / <br /> Pito �irouinspection by * //`/C t Date Z yZ Findl Inspection by Date L 9 <br /> Additional Comments: �/ G'�i - 16,"� ��� �_G, �l L7 �V�/ 411114 2, <br /> em .�� <br /> 1"a //I,,t� <br /> Applicant - Return all copies t0: San Joaquin County Public Health §ervices (JAL. l4h#_-L <br /> - <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, 3tkn, CA 95201 <br /> INEE OUNT DUE AMOUNT REMITTED CK III <br /> CASH RECEIVED BY DATE PERMIT'NO. <br /> W n Grv.cC'�c� <br /> EN 1?-21(REV.I/HSI <br /> � t�,� � .� - .. 1� <br /> fx <br /> EH 762a .LGA � `� � 2 � /� <br />