SU0011266 SSNL - Laserfiche WebLink

Home Browse Search

�I n APPLICATION I 4� F— /O{O�-y� S SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 6e02�&:;u ENVIRONMENTAL HEALTH DIVISION 4 445 N SAN JOAQUIN, PHONE (209)468-3420 A M -(�JJ q a � I ` P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED / � J (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 797 9 Cityeeaftv1'°t Size/Acreage 16�- Owner's Named Address 'a 7 �sP`hone �j��eS�O�Z Contractor a- Address License Nit d35_7�Y PhonedZ499Q;,� TYPE OF WELL/PUMP: NEW WELL ClWELL REPLACEMENT EIDESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLP. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ F i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing ^ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications i 1'1 Public 17 Other n Delta Depth of Grout Seal Type of Grout — I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. - _ State Work Done_ I � Selling Material L Depth Well Destruction ❑ Well Diameter I Depth Filler Material i.Depth t TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200.feet.) Installation will serve: Residence 4_� Commercial_ Other '--NUmbar-of-kvingvnits:_ T —Numberof-bedrooms— — —"'----------'--'— --Character of of loll to a depth 03 lee};. /'f%4?._ =' ,1'A� Water table depth e SEPTIC TANK. L9—Type/Mfg c -�OSC_ Capacity /6i.(f.� No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation.rte�0 Property Line s LEACHING LINE C4--No. Length of lines C��-f� �es{' � �� ♦�Toltal length/alae �0 FILTER BED ❑ Distance to nearest: Well / `— Foundation r, f Property Line 40 r SEEPAGE PITS W Depth .2s t Sire Number _7. SUMPS LI Distance to nearest: Well�le� Foundation Property Lino �YOf DISPOSAL,PONDS ❑ 1 hereby certify that 1 have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and, �r rules and rogulationt of the San Joaquin County iii Home owner or licensed agent's signature certifies the following: "I certify that in the polformance of the work for which this permit is issued, I shall nor employ any person in such manner as to become subject to workmates compensation laws of California." Contractor's hiring or sub-contracting signature sonifies the following: "I certify that in the performance of the work for which this permit Is issued. I shall employ persons subject to workman's compensa- �' tion laws of California." The applicant m ll for all r ued iurpections. Complete drawin on my rse side. �x p Signed K "Lsf p Title: �Gt�.Ut li Date: FOR DEPARTMENT USE ONLY y Application Accepted by ��e.-bl9 �hD�L-.+ ccs" / Date �1 ��-��/4 Area 1� 2-- I Pit or Grout Inspection by Date Final Inspection by Data '- Additional Comments Applicant - Return all copies to: San Joaquin County Public Health Services r Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, GA 95201 cam. t�CYj, IN O AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT'NO. E j REV.,,.,t N 1yt0 6368 Ia �S 93 �i3-GZ b