Laserfiche WebLink
;} 3 APPLICATION SCANNED <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ( ENVIRONMENTAL HEALTH DIVISION <br /> n 445 N ! AN JOAQUIN, PHONE (209)468-3420 <br /> P ` BOX 2009i STOCSTON, CA 95201 .1 <br /> PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED <br /> II (Complete in Triplicate) <br /> A»rkisatlon to hereby indde jo Elan Joaquin County for a pertait to construct and/or install the work herein described. This <br /> application to made is eamX14166 trttih All "bil le► Cool y brdihil Na. SI+P whd J460 iitd the All had 1t0e16111.4tleni of San <br /> Joaquin County Public Health Servic I <br /> 7� <br /> Job Address go +r !r ra V, City Lot Size/Acreage <br /> Owner's Name ���/ � O ' +I 1 - Address - .__ Phone <br /> 92 Ph �Lic No. S'& � 0� �Contractor J / 2 <br /> TYPE OF WELL/PUMP: NEW WELL ID WELL REPLACEMENT DESTRUCTION Out of Service Well 0 <br /> PUMP INSTALLATION 1l SYSIEM REPAIR El OTHFA ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANKOfte4l SEWER LINES Q� DISPOSAL FLD. PROP. LINE Zf�O <br /> FOUNDATION 1� At9RmuyrURlt WELL OTHEh WELD PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial C] Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> K Domestic/Private Lit Gravel Pack ❑r Tracy Type of Casing „f'!i� Specifications <br /> I'I Public Cl Other 1� Delia Depth of Grout Seal do Type of Grout <br /> 1 <br /> I I Irrioation 7�pprotr. Depth 13 Eastern Suilace Seal Installed by 4ZAI L&L&A< <br /> Repair Work Done C} Type of Pump i' H.P.. State Work Done <br /> Well Destruction Well Diameter Sealing Material & Depth <br /> Depth 3 �t Filler Material i Depth <br /> TY WORK; NEW INSTALLATION Cl REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sews ' <br /> 1 available within 200 }est.l <br /> Initallalion will r<eive:' Aesjdence— Cornmercla <br /> 4 Number of living units: Number of bedrooms . <br /> Q Character of Solt to i depth of 3 feet: Water table depth <br /> �- SEPTIC TANK ❑ Type/Mfg acity Na, Gompirtments <br /> Pill TREATMENT PLT. 0 ethod of Disposal <br /> Distance to nearest: Foundation Property U <br /> LEACHING LINE C1 No. 6 gth of lines Total length/Size <br /> r FILTER BED istance to nearait: Well . ? Foundation - - - Property Line <br /> . SEEPAGE P 11 Depth �� Si:e '3 Numbsr <br /> SUMP LI Distance to nearelt: 1 Well Foundation Property Line <br /> `! D OS <br /> PONDS <br /> I hereby certify that I have prepared this applicaiion!end 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 II <br /> Homs rwner or ISE agent's signature certifies the following: "I certify thai In the performance of the work for which this permit is issued, I shall not <br /> employ any son in suc nner as to become t to workman's tornpsnsation laws of California."Contractor's hiring or sub contracting signature <br /> certifies t followingja. <br /> ify the In th perfo Sri` of the work for which This permit is issued, I shall employ persons subject to workman's compensa <br /> tion la of Cali'or The ap Ncant ll r Ulf Com lets dr ave side. g <br /> Signed k Title: Date: <br /> ENT USE ONLY <br /> Application Accepted by Date �L Area S` <br /> Pit o ►out spection by Date � I~Inal tnepection by Detel—z <br /> Additional Comments: <br /> Applicant - Retur all copies to: San Joaquin Couritq Public II lth Service <br /> Suvironmental Health Permit/Services ' <br /> 415 N San Joaquin; P O Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 11Y DATE PERMIT'NO. W r <br /> . tH 13-74IREV.r i n S) <br /> EH 14-20 WK g .t;,o Cp�IV2 92 aa?a7 W p <br />