Laserfiche WebLink
APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEA '�y <br /> ENVIRONMENTAL HEALTH III ISa�{�� �u} •••"'�^^^--- ^^^��+ rr <br /> 445 N SAN JOAQUIN,PHONE(209) 643420 <br /> P O BOX 388,STOCKTON,CA 952 1 # <br /> PERMIT EXPIRES 1 YEAR PROM A11WftIMSTIED <br /> (Complete in Triplic ''n�L11xfv IIIIiii <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work here' de{�TLtd.Rh lance with San <br /> Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the <br /> Rules and Regulation in unty Public Health Services. <br /> Job Address /�? LtTJ 619 9 \J Tam ��E, ,/� City Lot S3 a/Acre <br /> Owner's Name ✓ [� �Y A �' 7FJ 'T/I r Address Phone <br /> Contractor JL CACA:a a •1 Address 119 / CC-Cl' License No. -43y Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out 01' service Well ❑ <br /> PUMP INSTALLATION � SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK t�r✓� SEWER LINES DISPOSAL FLD.'— PROP. LINE = <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C ,. <br /> C, Industrial pen Bottom ❑ Manteca or,. of Well Excavation Dia. 01 Well Casing QX) <br /> P.. orrustic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ 6/"-'4 Specifications <br /> ZC <br /> 11 Public CI Other fl Delta Depth of Grout Seal —+)'M — Type of Grout <br /> r� a <br /> I I Inigalion Jj!LL Approx. Depth I I Eastern Surface Seat Installed byV <br /> Repair Work Done ❑ Type of Pump `�— H.P. ­�S State Work Done_ <br /> Well Destruction ❑ Well Diameter sealing Material i Depth <br /> Depth _ biller Material a Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public newer is <br /> available within 200 lest.) v <br /> I <br /> Installation will wrve: Residence_ Commercial_ Other ��y1 <br /> Number of, - units: _ Number of bedrooms <br /> Character of sod to of 3 fest: Water <br /> SEPTIC TANK ❑ � Capacity Ido.-Cdi"npart / J <br /> WN <br /> PKG. TREATMENT PLT..O - Method o/ �f �ay1 <br /> Distance to nearest: Well etin o Property Line <br /> 1! <br /> LEACHING LINE ❑ No. 8 Length of linea �"� � Total Ian ' a <br /> FILTER BED ❑ Distance to nearest.--"Wall Foundation PropsU . M$�RVIQy <br /> M ' I l <br /> SEEPAGE PITS I pth Sue Number �u�Yy YY <br /> SUMPS LI Distance to ruarot Well Foundation Property Lim <br /> DISPOSAL PONDS ❑ <br /> 1 hereby cenity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Iews, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I cenity that in the performance of the work for which this permit is issued, I shall nor <br /> employ any person in such runner as to become subject to workman's compensation Iawe of California." Contractor's hiring or sub-contracting signature <br /> canifies the following: ­1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must all`.f�o1 MI required nspections. Complete drawing on reverse a d _ <br /> Signed x 4 '� Title: 12 "7 Date: 'S -.2� `_@/el <br /> FOR DEPARTMENT USE ONLY �7 <br /> Application Accepted by 41n_n � Date i- <br /> Pit orro t Inspection by Dat � `YFinal Inspection by Data <br /> Additional Comments: 1 r. <br /> Ap11c Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health PermiL/Services LL{{3 R0 S R.G�3131 — Tau V —t,p t <br /> 445 N.San Joaquin,P.O.Box 388,Stockton,CA 9520Y%388 a'a <br /> I1� <br /> ''SIL INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> VJ <br /> N <br /> ­1Mla.ae(REV.1/"el d <br /> EM I..y 1,L- <br />