Laserfiche WebLink
APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN,: PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 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 /> 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 /> Job Address _ NC�t YC.('1 Q City L Lot Size/Acreage <br /> Owner's Name VA cges-1MWddressC��D „�(«�,C PhoneW1 4 l \ <br /> Contractor Address Icense No, Sb'LPhone .- -7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION 0 Out of Service Weli ❑ <br /> PUMP INSTALLATION i SYSTEM REPAIR J' OTHER 0 Monitoring Well U <br /> DISTANCE TO NEAREST, SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private C] Gravel Pack� ❑ Tracy Type of Casingsing <br /> _ Specifications � <br /> I'1 Public C) Other n Delta ' <br /> &ofow Seal .Type-of Group•1�4rrigation Approx; Depth I I Eastern Installed by <br /> Repair Work Done 0 Type of Pump MkeJ5LAA H,P, State Work DorieWell Destruction 0 Well Diameter SeaDepth <br /> - •_ cmc.j/Z s� <br /> Depth Filler Material & Depth. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I lNo septic system permitted if public sewer is <br /> k 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: <br /> -Water table depth <br /> SEPTIC TANK ❑ Type/MfgI Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line r <br /> it <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ , Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I Depth I Size Y Number <br /> SUMPS CI Distance to nearest: Well; Foundation_ <br /> DISPOSAL PONDS C7 Property Line <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 taws, 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, f 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: "1 certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- <br /> tion taws of California." <br /> The applicant mus <br /> ll far all re wired inspections, replete drawing on verse ide. [[�� <br /> Signed ` "`"°' <br /> Title: � _ _ Date: 3—/rJ�_�� <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by <br /> t <br /> Date Ar_aa c <br /> Pit or Grout Inspection by f Date Final Inspection by ^~ <br /> Date <br /> Additional Comments. <br /> Applicant - Return all eopies'to: San Joaquin County Public Health Services <br /> '# Environmental Health Permit/Services <br /> 1 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> d <br /> FEE AMOUNT DUI AMOU T REMITTEDCK <br /> yINFO CASH RECEIVED 8Y DATE PERMIT'NO. <br /> . EIS 13.2 IREV,tiKslCH 14-21 <br /> M <br />