Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES M <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 f <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> l <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 1 62 and the Rules and Regulations of San <br /> Joaquin County Public Hea'llt��h/Servi e . <br /> Job Address `� "" City Lot Size/Acreage C? 7 or - "� <br /> 4 [ee Phone` y ^ i <br /> Owner's Name Address 4�'�. t <br /> Contractor -Address ! :5..� - --License'No �Phone — - <br /> TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C3 Out of Service Well 0 <br /> PUMP fNSTALLATION ❑ SYS M REPAIR C7 OTHER ❑ Monitoring Nell L7 i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ISPOSAL FLD. PROP. LINE <br /> i <br /> FOUNDATION AGRICULTURE WliLL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONS TION SPECIFICATIONS <br /> ❑ Industrial _ 0 Open Bottom_❑_Manteca Di o Well Excavation Dia. of Well Casing <br /> C:1 <br /> Domestic/Private 0 Gravel Pack ❑ Tracy ype f Casing_ Specifications <br /> I"I Public 1-1 Other F1 Delta Dept of Grout Seal Type of Grout <br /> I I Irrigation �.Approx. Depth I I Eastern Surf a Seal Installed by_ -- <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I 'REPAIR/ADDITION I DE TRUCTION I I INo septic system permitted if public sewer is <br /> a able w' hin 200 feat,l <br /> i _ <br /> Installation will serve: Residence� Commercial her /f h <br /> Number of living units: Number of bedrooms /V 0 � � ,Lc,�, <br /> yr i <br /> Character of soil to a depth.of 3 feet Water table depth <br /> SEPTIC TANK . 0 ,Type/Mfg l Capacity No. Compartments j <br /> PKG. TREATMENT PLT. 0 Method of Di sal <br /> Distance to nearest: Well Foundation Property Line <br /> 1 <br /> LEACHING LINE 0 No. & Length of lines To al length/size <br /> FILTER BED 1„w-,,_q__Distance to nearest: Weil Foundation Properly Line <br /> SEEPAGE PITS r i I Depth Sire Number <br /> UM— LI Distance to nearest: Well Foundation Property Line" 1 <br /> ISPOSAL PONDS ❑ <br /> I hereby certify the!1 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•licensad agent's signature cerlifies 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 hiring or sub-contracting signature <br /> certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." ! <br /> The applicant mus call for all raKred inspe ions. Complete drawing on reverse side. <br /> Signed X Title: - Date: <br /> DEPARTMENT USE ONLY"r . <br /> FCCyys�V Area oi 4 <br /> Application Accepted by &Cmb. - _ _ __-- Data—L— � <br /> Pit or Grout inspectiori'by Date Final Inspection by Date 1� <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services "ern <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. <br /> { I CASH <br /> . EH 13-24IREv.rills r/f! 013—\- �LLq� <br /> EN 14-M /A/ Z/Y <br />