Laserfiche WebLink
a' APPLICATION FOR PERMIT <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 in hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in ccWVliance 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 t!d iA �%C.l1f-, City Lot Size/Acreage <br /> Owner's Name I.J Address �' Phone <br /> Contra. Addre� cense N -3 Phon <br /> TYPE OF WELL/PUMP: NEW WELL O / WELL REPLACEMENT n _DESTRUCTION C) Out of Service Well O <br /> PUMP INSTALLATION B� SYSTEM REPAIR &-- OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLP. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> !N ED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ndustrial O Open Bottom _ O Manteca Dia. of Weil Excavation Du. of Well Casing <br /> 51 Domestic/Private O Gravel Pack L7 Tracy Type of Casing_ Specifications <br /> 11 Public 171 Other n Delta Depth of Grout Seal Type of Grout <br /> I i Ir6ostion Approx. Depth I 1 astern ^� Surface Seal Installed by <br /> Repair Work Done U1 Type of Pump H.P. .7 0 State Work Done i <br /> Well Destruction O Well Diameter Sealing Material i Depth , <br /> Depth biller Material i Depth <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-1 1--REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> 1 F available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other ' r <br /> Number of living units: Number of bedrooms i t <br /> Character of soli to a depth of 3 fat: <br /> SEPTIC TANK O Type/Mfg <br /> Capicity r ' n, , <br /> _ V D <br /> PKG. TREATMENT PLT.0 <br /> Distanceto nearest: Well Foundation p � - <br /> LEACHING LINE O No..3 Length of lines Total Is r <br /> FILTER BED O Distance to nearest: Well Foundation <br /> - _-� ;{ ----�t®fRe'idAMp{V'A4�ALTli-DIVISION t <br /> SEEPAGE PITS ; 11 Depth Size Number ` <br /> SUMPS Cl Distance to nearist: Well Foundation Property Lina <br /> DISPOSAL PONDS O_ ^'- <br /> I hereby cenify,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 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-ouch.menner as to become subject to workman's compensation laws of California." Contractor's hiring or tub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." I <br /> The applicant must cell for uired in Owns mpkte drawing onrev a side. <br /> Signed Title: Date: to /3 <br /> - - - OR DEPARTMENT USE ONLY <br /> d2Zo <br /> Application Accepted by Data ^ Ares �` <br /> Pit or Grout I J ' ~ / <br /> napection by Date ~ Final Inspection'dy Date -2-1,'122 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT OVE IAMOUNT REMITTED K RECEIVED BY DATE PERMIT NO, <br /> INFO `/r <br /> . EH 1y74 f11tY.r i n sl � �}-� n-,.l LL C- w--.l 70�r /' -. .�.. /�� n- --- <br />