Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, 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 and Regulations of San <br /> Joaquin County Public Health Servi <br /> Job Address City <br /> �y__�__ bo Size/Acreage <br /> Owner's Name 7 T Address V + • Phone <br /> --Gontfactor/ i T , dress , icense'No:�' YJ <br /> Pf1ut1E' �~ 1Z <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION ❑ Out of Service We11 ❑ <br /> PUMP INSTALLATION ❑ SYSTEM EPAIR In OTHER D monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES i POSAL FLO. PROP. UNE <br /> FOUNDATION AGRICULTURE WELL ►OTHER WELL PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONST !ON SFPECIFICATIONS <br /> n Industrial---❑ Open Bottom ❑ Manteca ;(ViP"4;,, <br /> We Excavation Dia. of Welt Casing <br /> El Domestic/Private ❑ Gravel Pack El Trac f C sing_ Specifications <br /> t <br /> F] Public (-1 Othdr• C1 Deha,_ Depth of rout Ssalr Type of Grout <br /> I i Irrigation} Approx. Depth I I Eastern _Depth <br /> eai Installed by <br /> k <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ <br /> i <br /> � Well Destruction El Well Disilnetef' Sealing platerY � al i•Depthl -- <br /> Depth ` Filler Material i Depth <br /> 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIAIADD TTION I I D�TRUCTION I INo septic system rmiIted if pUhl' <br /> sewer is <br /> �v4ikabfe ithin 2 feet.) <br /> Vol- <br /> Installation will serve: Re idence Commercial Other ^�� <br /> Number of living units ---Numberof bedrooms <br /> Character of soil to a depth of 3 feet: In Water 10°1t {- <br /> I SEPTIC TANK ❑ Type/Mfg `Capacity- -_ _ No. CciMpartrrlents (• <br /> � <br /> PKG. TREATMENT PLT. 0 ' _ <br /> � �� � ` • >� � � .,..,Method dt"`Di al' <br /> Distance to nearest: '° Well undation-f ` Property tine <br /> JI t <br /> LEACHING LINE ❑ No. & Length of lines._ ITot l length/size <br /> r <br /> FILTER BED_ _ yQ Distance to nearest: • Welt�ly¢oundation� roper <br /> Pty Line <br /> SEf PAGE PITS){ ! I I Depth Size' Nu bar SaMPS -+l.l,--Distance-to n rest: Well Foundation Property).ins <br /> DISPOSAL PONDS ❑ i <br /> ..i 1he'reby_tertify 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 i <br /> Home owner or licensed agent's signature certifies the following: "I cortify that in the performance of the work for which this permit is issued, I shall nott <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 /> C— ifiei the following: "I Certify that in thn 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 mu cal.14or aN ired ins tions. Complete drawing on reverse side. <br /> F v <br /> k Signed Title: Date: ` <br /> FOR DEPARTMENT USE ONLY <br /> ✓ � ,� f -��, <br /> rApplication Accepted by Date Are �^ <br /> �ti( , t <br /> ft or Grout Inspection by Date '�.I-Final Inspection by a Data <br /> 'L <br /> 1 Additional Comments: � '""�•'" ; w `� / -�`a i <br /> ti �tD' ✓�dW�' L � <br /> y Applicant - Return all copies to: San Joaquin County Public Health Services <br /> rn <br /> r t EavixonentaA Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT�REEMITTED CASH RECEIVED BY DATE PERMITNO. <br /> . E H1724(RSV.t/x 5) /�� .�p �� <br /> f 14.25 `I <br /> 4m <br /> 1 <br />