Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL+ HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PRONE (209)468-3420 <br /> P O BOX 2009, STOCSTON, CA 95201 <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 <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules aad Regulations of San <br /> Joaquin County Public Health Services. <br /> 21 Job Address City Lot Size/Acreage 1 <br /> Owner's Name I Address E f� Phone <br /> I Contractor/s'/ &1% 5A_4�;Addme s - F _License No. _ &Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION Out of Service Well 0 <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ A 4%77/Q 9ER ❑ MonitoringrWell ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDES PO-SAL FLD. PROP. LINE <br /> N ' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL cR+'7_-- PITS/SUMPS i0 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 Dia. of Well Casing <br /> omesticlPrivate Gravel Pack I ❑ Tracy Type of Casing_ Specifications <br /> I'FPubfic ! it f�j n Delta Depth of Grout Seal Type of Grout r <br /> I I Irrigation App r , Depth I I Eastern uace EeaLl Installed by T' <br /> Repair Work Done U Type of Pump H.P.. State Work Done <br /> Well Destruction IV' Well Diameter Sealing terial & Depth <br /> Filler MaterialDepth <br /> Depth & <br /> � '--- <br /> TYPE OF SEPTIC WORK: NEW INSTAL l REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feel.► <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. 0 Type/Mfg "Capacity r No. Compartments r <br /> _ PKG. TREATMENT PLT. ❑ -- --- ----. ' _Method of Disposal � <br /> 'Z <br /> Distance to nearest: Well Foundation - P.ropeny Line _ <br /> LEACHING LINE Cl No. 6 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundations ; i' Property Line I <br /> a 3 <br /> SEEPAGE PITS I I Depth, Size Number <br /> ' SUMPS » 0, Distance <br /> -So nearest: Well �'� Foundation Property Line <br /> I <br /> DISPOSAL PONDS ❑ <br /> I hereby certifyithat I have prepared thiq 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 Joaqui County N,, r `, <br /> Home owner or licensed_agent's signatu a certifies the following: "I canny that in the performance of the wvork 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 warkman's compensa} <br /> tion laws of California."I } ,L <br /> The appticant" iegru4. tions. Complete drawing on revs a side. r ? <br /> Signed XTitle: "'~ =} Date: 7 � J <br /> R PARTMENT-USE ONLY <br /> t}.f Application Accepted by Date" Area <br /> Pito Gro Inspection by Date f Final In,ectiori by <br /> A <br /> Additional Comments: L <br /> a�- IGS <br /> Applicant -Return all copies- o: Ran Joaquin Co ty Publid'Health Services )1' <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INPE AMOUNT DUE F AMOUNT REMITTED GASH AECEtVE0 9Y DATE PaNO. <br /> . EM13.21eREV.iinsi L� •Q� L `QG� -3oL_ <br /> EH 14411 L <br />