Laserfiche WebLink
SAN UIN COUNTY PUBLIC HEALTH q&VICES <br /> VIRONMENTAL HEALTH DIVISI e , �- q <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 // <br /> P O BOX 2009, STOCKTON, CA 95201 (y <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED b6 <br /> (Complete in Triplicate) !t 5 <br /> made to Sen Joaquin County for a permit to construct and/or install the work hefelh ascribed. This <br /> Application is hereby 4 <br /> application is made In compliance with Ben Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> q� �� City Lot Size/Acreage — <br /> Job Address <br /> y r LJI^ Phone sG�/ <br /> Owner's Name T � Address �{,�j -- <br /> Contractor <br /> Address /1�l.lV �5fLicense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT 11 DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR O <br /> OTHER O Monitoring Well <br /> DISTA CE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> NTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f I Domestic/Private O Gravel Pack O Tracy Type of Casing__ Specifications <br /> i'I Public 1 ter n Delta Depth of Grout Seal _ Type of Grout <br /> I I Irnpation t � Approx. Depth 11 Eastern Surface Seal Installed by <br /> RApair Work Done LJ Type of Pump H.P. Statc Work one _ C�F> <br /> Well Destruction Well Diameter Sealing Material Z Depth '¢ <br /> Depth <br /> Filler Material i Depth <br /> 1 YPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I available e w thin 200 fe trued it public sower is <br /> Installation will serve: Residence_ Commercial_- Other <br /> Number of living units: Number of bedrooms Wat PAYM NT <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK O Type/Mfg Capacity No.o.A�� <br /> PKG. TREATMENT PLT. O MetFIg01g1 L#is�s <br /> Distance to nearest: Wbll Foundation Propeb1APJr3 �NTY <br /> PURI Elm' <br /> 7L ecettrnrn <br /> LEACHING LINE L1 No. b Length of lines Total Ie9MWR9 MENTAL HEAL TH LII 4*N <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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 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 per n in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifieAh,, w ing: "I Certify that i he Ewterrt�e of the work for whit this permit is issued, I shall employ persons subject to workman's compensa <br /> tion lawThe aps caIr all re inspections. Complete drawing on eve side.Signed <br /> Title: Date: <br /> R DE ARTME-NrbSE ONLY p <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public health Services <br /> Environmental Health Permit/Services <br /> q445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> Ua AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> V(`EH 13241AEV.I/m51 l e o • �V � IN /17 <br /> /-, <br /> EH 14 26 llll,,,,,.LLLLLL <br />