Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION � <br /> 445 N SAN JOAQUIN, PHONE (209)468-342b <br /> 0 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> FILE 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 <br /> application is Stade 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 7ea .tv City !!g4 4,,o Lot Size/Acreage _ <br /> Owner's Name 0��Gc`J J A55 Address Phone - 1 <br /> Contactor" ll(ere . -.Address , D L!_D_ Z.#,T/"Lidense Nc� Phone _ <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER d Monitoring Well C7 <br /> y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE u TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> rO Open Bottom - O Manteca pia. of Well Excavation Dia. of Well Casing <br /> n il;du s I—,--I <br /> C.1!Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ _ Specifications �\ <br /> I"l Public (.1 Other 11 Delta Depth of Grout Seal Type of Grout <br /> I Inigatwn _ Approx. Depth I I Eastern Surface Seal Installed by <br /> Re'p3i'r"WOilt"Oi)fS2'"`U-""7y-p'e oT-Pump H.P. State Work Done <br /> Well Destruction—• 0 Well Diameter Sealing Material d Depth <br /> Depth Filler Material 6 Depth <br /> TYPE OiF.;SEP, _W <br /> TIGORK; NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 leet.) <br /> Installation will serve:, .Residence_ Commercial Other <br /> Number of living units: Number of bedrooms 3 <br /> Character of boli to s depth of 3 feet: Water table depth <br /> SEPTIC TANK l ' :D Type/Mfg Capacity No. Compartments ^ <br /> PKG. TRg_AJMENt'k ❑ Method of Disposal \\U <br /> • r <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE i Cl No. & Length of lines OZ YO S� rT Total length/sif� <br /> FILTER BED t t'i-K-Distance to-nearest: Weu,6 TFoundation d&:21'; - Property„•Line _ w - <br /> r i <br /> t <br /> Number _ <br /> SEEPAGE PITS l � 11 Depth Size <br /> SUMPS LI Distance to nearest: Well Foundation Property Line ' <br /> DISPOSAL PONDS ❑ <br /> I hereby ceAity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and'regulauons of the San Joaquin County <br /> Home owner orlicensed.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-workman's compensation laws of California.” Contractor's-airing or sub-contracting signatuie l <br /> cenifiss 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 iimpenW <br /> tion laws of California." <br /> re tired in actions. Complete drawing on,reverse side. <br /> The applicant must call for a 19� <br /> Title;TitlDate: <br /> Signed � Y <br /> DEP Y p <br /> I Area <br /> Applivsetlon Accepted by J -- <br /> Pit or Grout Inspection'by Date Final Inspection to Det <br /> Additional Comments: <br /> Applicant - upturn all copies to: San Joaquin County public Health Services -, <br /> II Environmental Health Permit/Services <br /> r� 445 N San Joaquin, P.O Boa 2009, Stkn, CA 95201 ` <br /> y <br /> kg? ---E AMOUNT REMITTED CK RECEIVEDBVATE __ PERMIT NO.-- ._.._ -.l/ 1 /D <br /> EM 1344I11EV.,ieW <br /> EH a 26 <br />