SU0009491 - Laserfiche WebLink

Home Browse Search

f APPLICATION FOR P&ALIT SAN JOAQUIN COUNTY PUBLIC HE � VICEa��9/ G ENVIRONMENTAL HEALTH D V a 445 N SAN JOAQUIN , PHONE ( 0 3420 P O BOX 2009, STOCKTON, PERMIT EXPIRES 1 YEAR R Y (Complete in Tripli< ato # / 5 Application Is hereby made to Sian Joaquin County for a permit to construct I'V�(I 1a application in w%de in couplisnce with San Joaquin County Ordinance No. 549 and lite and the Rules aui<t retius or tran Joaquin County Public Health Services. p (� ---��jj Job Address - : E(5 cc �df"�1'rEy SC7f7 E.-'V - Cnv(Ce45t>/ Lot Site/Acres.Se L Owmer's Name ,-ogf L_ �`t-M b�If(J�y G Adldrresls� _ I� (� Phone Conllactor Ff 4t i �` i _!,�yy Addresl l `Ca /(/E �r rti License No AL— Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F) DESTRUCTION ❑ Out of service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ Manteca Dia. of Wall Excavation Dia. of Well Casing Cl Domenic/Private ❑ Gravel Pack ❑ Tracy Type of Casing___ Specifications I Public I:1 Other Cl Delia Depth of Grout Seal Type of Grout i I litigation _Approa. Depth I I Eastern Surface Saul Instalksd by Repsa Work Done ❑ Type of Pump N.P. Stay Work Dona Well Destruction ❑ Wall Diameter Sealing Material a Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADOITION I I DESTRUCTION 1 I (No septic system permitted it public Sawa, is ' / available within 100 feat.) Installation will"No'. Residence v Commercial_ Other Number of Irving unit': Number of bedroomsg Cheraw of epM to a depth or 3 feet: � , Water table depth SEPTIC TANK ❑ Type/Mfg ��- L- CApacit No. Compartment' OL- PKG. TREATMENT PLT, ❑ Method of Disposal�7-�s� Distance to nearest: Wall u✓00 Foundation �1� �r Property Line �7 LEACHING LINE *VL No. g Length of lines _�� _ y�7 Total length/size 7— FILTER FILTER BED ❑ Distance to nearest Well /em*r�Founcjsuon 'ea r Property Line >Un psi SEEPAGE PITS 11 Depth 1cT Sire _y!!5t-1T J�r Number SUMPS D( Distance to fesest'. well LA-- "Foundation Z2 r" Propiny Lina DISPOSAL PONDS ❑ 1 hereby Conley that I have preosred this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and rules and regulations of the San JOagwn County Home owner or licensed agent's signature Sonifies the following: "I Certify that in the performance or the work for which this parrot is issued, I Nall not employ any portion in such manner riff to became subject to workman's compensation laws of California."Comfector'a hiring or suPcontrscting signature canifies the 1000wing: -I certify IhAt In 1M perfOEmance of the work for which this permit is issued, I shall employ persons subject to workman's componsa- lion lows of California.- The applicant must jell for rt liedIn cttiinse yo's. Complete drawing on rover" side. �y h p Signed K -'r ,�`e Title: 'Ia lw�-.> Date: ��/ -93 AMA FOR DEPARTMENT USE ONLY q Application Accepted by /"`MA 0 Data � - � � -� Area d`du_ Pit or Grout Inspection by Date Final Inspection by Aex^ Date Additional Comments: Apr.11cant - Return all copies to: San Joaquin County Public Health Services �\ Eavlromnental Health Permit/Services /1G r 00/l�/ (/ 445 N San Joaquin, P 0 Box 2009, Stan, CA 95201 VV a FEE AMOUNT Dt/E AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. IN,FiO (fir I' I1 /+ C`ArSiN •�// �/r . rs nitx IRIV.1 r•er`/v 11 U1r Iii G✓ / Oi / � & `' I ! � /liq I qo EM tE.re J