SU0003878 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT IA sqb� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES .gqPyll' �� ENVIRONMENTAL HEALTH DIVISION �yr' �q1- O00" 445 N SAN JOAQUIN, PHONE (209)468-3420 i/ P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby ands to Sian Joaquin County for a permit to construct and/or install the vork herein described. This application to made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. C7 :C Job Address � I ��/� FI � ` / City�'��3� �^� Lot size/Acreage Y S(2 �,7 / / Owneis Name >'7'�i�'Y r�< I/C'•' Address / /I� 1`7'f'flrt S�-Kc/ ��i-)_L Rhone ' "^5 L 0 Contractor ,' fif ti Address AjJ, °/s 35-7 License No. Phone TYPE OF WELL/PUMP: NEW WELL' WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK ZC'0" SEWER LINES -'d- "'-1 DISPOSAL FLD. PROP. LINE /%'G' �,- FOUNDATION l<.=N ' _ AGRICULTURE WELL OTHER WELL,3J,/ i PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing r<ponastic/Private ;L<('iravel Peck ❑ Tracy Type of Casing_ _Pr C-. Specifications.T� I'1 Public ❑ Other ❑^Delta Depth of Grout Seal Type of Grout 11 I I Irrigation ��Approx. Depth I I Eastern Surface Seal Insullsd by MAr u//r? Repair Work Done U Type of Pump M.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth _0 Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i (No sept;within em permitted if public rawer is available 200 feet.) Installation will serve: Residence_ Commercial_ OtherNumber of living units: _ Number of bedrooms Character of soli to a depth of 3 feet: Wala ds SEPTIC TANK ❑ Type/Mfg Capacity No �6�..cPKG. TREATMENT PLT.❑ MCE4WO Distance to nearest: Well Foundation Property _ �1 ` V "—J LEACHING LINE ❑ No. 6 Length of lines Total length/ig UIN C FILTER BED ❑ Distance to nearest: Well Foundation ProB1}$"EA wiOptiISION F NVIRONME91 C 11 SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to rasrest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sen Joaquin County 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of tub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compenu- tion law.of California." The applicant at call for all requ/irg/d in ,octions. Complete drawing on reverse side. Signed >L� l L t111,11-C f'� 1 Title: Data: DEPARTMENT USE ONLY c• •� 1 Application Accepted by '•• '. ../ e. Dau .L —� Area Zy I Pit or rout tion by /.&,g -(Date 7 ��_ Final Inspection by f Dau Additional Comments: , !— Z�� i J � 1 4� n ay ` � f Applicant - Return all pies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N Sao Joaquin, P O Box 2009, 3tkn, CA 95201 FEECK a INFO (A'A(M\\OUNT yO,UE AMOUNT REMITTED CASH RECEIVED fly DATE PERMIT'NO. . FN t}24(REV.I I A 5) V� 'oV ® iFv � 324 //��}: P_ FH 14.2E J