Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N Spy« JOAQUIN, PHONE (209)469-342L <br /> P 0 BOX 2009, STOCKTON, CA X15-j1 <br /> 2EWT E%PIRES i YEAR eRrA_D:a ISSUED <br /> Complete is Triplicate) <br /> Application is rwreby jade to Ban Joaquin County for a permit to constrrret and/or install the work heroin described. This <br /> application is made In coopliance with San Joaquin County Ordinance Mo. 50 arvl 1862 and the Rules and Regulations of San <br /> Joaquin County PUb11C Health Services. <br /> 'ob Address 619! 'E' y►p,fyl n _ _._ /)�/aI' 4e_ Crtv 1"+SL_^= Lot Sizte/Acrease Q 'e <br /> Owner's Noma Mt1410 Pt i'I) r Address �'[� 6ol d 1 S�t_1'/Q/l l ._ P. <br /> Contractor m o�i e hme Addr.ss s f3° �Q�C License No.�{�(.57 Phone <br /> TYPE OF WELL/PUMP NEWN:ELL WELL REPLACEMENT 1-1 DESTRUCTION o Out of service -loll Lj <br /> PUMP INSTALLATION SYSTEM f�E�oIR L1Monitoring Voll OTHER ❑ � n <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 610 DISPOSAL FLD. PROP. LINE law <br /> FOUNDATION �_ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATtQNS s <br /> D Irdustnal O Open Bottom ❑Manteca Dia.of Well Excavation Die.of Well C.... <br /> I on»nic/Private Gravel Pack O Tracy Type of Canny_ Specifications <br /> I Pnrbfic Pll_OthIy/rr n Delta Depth of Grout Seel Type d Grout <br /> I I Irrigation �"�APprox. Depth 1 I Eastern Surrsce Seal Installed by <br /> Repair Work Dona U Type of Pump N.P. —7 Stats Work Dona_ <br /> Well Destruction O WW Diameter Staling 1`tsrial E Depth <br /> NWh Tiller Material E Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 i REPAIR/ADO1TION( I DES'RUCTION I I INo septic system permitted if pfikc sour*#is <br /> available within 200 lost.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> hivmber of living units: Number of bedrooms <br /> Chorachor of moll to a depth of 3 feet:_ Water table dept_ <br /> SIPTIC TANK O Typo/Mfg __ Capacity No.Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br />+ Distoma to naarsat: Won Foundation Property Lire <br /> LEACHING LINE C. No.&Length of linea __ Total length/oke <br /> FILTER BED 0 Distance to.nearest: Well Foundation Property Lire <br /> d <br /> SEEPAGE PITS I I Depth Sin Number <br /> SUMPS LI Distance to newest: Won Foundation_ Property Lire <br /> DISPOSAL PONDS O <br /> 1 hereby certify that I he"prepared this application and thY the v rork vill be dons in accordance with San Joaquin county ordinances,state lows,and <br />` rules end ropulsiione of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the fonowrng: "I certify that in the performance of the work few which this pormrt is issued.I shsll not <br /> orhploY any person in such manner as to become subject to workman's compensation laws of Coliforms."Contractors hiring or oub-contracling apnature <br /> certifies the following:"t certify that in the psrfomwice of the work for which this permit is issued,i sha!I employ persons subject to workmen's compensa- <br /> tion lova of <br /> The applic st tall for M 1l13� d Inape est.Ce el swing IM mtvsrse aide. <br /> Title: y/GI. /// r• Data: <br /> FO D@PARTMENT USE ONLY <br /> I <br /> Applkotbn AeeeptW by Dots `� Ana '4 <br /> PM ol.�' tion by no-li=i!�l�'R Final Inspoetion by Date .. <br /> Additional Comments: f;�`f>t✓��/af ! . ,� <br /> Applicant - "eturn all copies to: San Joaquin County Public Health Servtcen <br /> EnviroaesntaI Health Permit/Jervicea <br /> 145 H San Joaquin, F O Dox 2009, 9tkn, CA 9n201 <br /> IFEE <br /> NFO AMOUNT DUI AMOUNT REMITTfO SM R[CIIVID W OAT[ VIRMIT No. k <br /> N <br /> IK f1/LI# !`IV { <br /> i <br /> 1 <br /> 1 <br />