Laserfiche WebLink
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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EBPIRES 1 YEAR FROM DATE ISSUED OFF SnTC <br /> (Complete in Triplicate) a/e7cL <br /> Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This <br /> application 1s made in califillance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. (CeQN£rL OF_Iwmes Ahtff:4E/2) <br /> Job Address 4o z dox/UE+2 AVE, S7a_K711J (fl 6,. / City S—/r0C�1r_-r$"j Lot Size/Acreage <br /> �fccnr!' l r flssoclATED µr/TN Mn2/-EY cor".m4 TMUf1C <br /> Owner's Name The Ziraxj•r Address Phone <br /> f}T' /50 N• 5/A1CGA/r!', Phone <br /> RI✓Rl. w4rin-L F. 0. 6PK2053� <br /> Contractor WP-c•t- 9RfLIL014 Address. 933dO 0License No. /5"D/3.3? Phone 9 - 912 <br /> TYPE OF WELL/PUMP. NEW WELL C3 WELL REPLACEMENT M DESTRUCTION n Out of service well <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /a9& SS&R4- 2 <br /> Y6i Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dim. of Well Citing P"Ar <br /> (I Domestic/Private O Gravel Pack ❑ Tracy Type of Casing- Specifications <br /> 1'I Publk (X Other M0A/frOp— n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth 1 I Eastern Surface Seal Installed by .e1✓AC kJf76t W&I- <br /> Repair Work Done L7 Type of Pump .Sdb&AS16LE H.P. !/Z State Work Dons <br /> Wee Destruction ❑ WON Diameter Sealing Material i Depth <br /> Depth Tiller Material a Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I Mo septic system permitted it public sewer is <br /> available within 200 feat.) <br /> Installation win serve: Resident"_ Commercial_ Other <br /> Number of living units: _ Number of bedrooms <br /> s <br /> Character of toY to a depth of 3 fwL• Water tabs depth <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ • Method of Disposal <br /> Distance to Interest: Well Foundation Property Line <br /> LEACHING LINE O No. A Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Wall Foundation Property Linty <br /> SEEPAGE PITS 11 Depth Sae Number <br /> SUMPS LI Distance to nearett: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 shall not <br /> employ any person in such manner as to become subject to workman's compensation Iowa of California." Contractor's hiring or sub-contracting signature <br /> coni ies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persona subject to workman's compensa <br /> tion lawn of Confomla. ' <br /> The applicant putt u o I e�uired Inapaetbns. Comptsta drewinp on reverse side. / <br /> Signed W3 <br /> Title: tTE(7 ff�// DGftJLrJGl�7- Date: �.3 ./ <br /> OEAc. � SoG•/ /��• <br /> /e/),�� FOR DEPARTMENT USE ONLY <br /> Application Accepted by sJ4 �'-`�_-�' Dats Area <br /> Pk or Grout Inspection by ,�] I,f/ ,/�[ Date Finale Inspection by Date <br /> Additional Comments: - 1-f r t'" '7 7���2L� GV'Q'a C(OLl YG fTzr <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 95201FEE <br /> "Y <br /> INFO AMOUNT DUE AMOUNT REMITTED I CASH <br /> g R,E/CEEIIVED aY rDATE PER <br /> RECEIVED y <br /> . [s ,a-zt laEv,ir.rel FM 14 AOKI /I' l'IO(, (Y?d� d I <br /> r—r <br />