Laserfiche WebLink
APPLICATION <br /> SAN IOAQUIN COUNTY PUBLIC HEA ZSewices.ENVIRONMENTAL HEALTH III IS��e�Rg {y{445 N SAN JOAQUIN,PHONE(209) 643420 P 0 BOX 388, STOCKTON,CA 952 IJRVD#PERM T IRES 1 YEAR RON SUED(Complete in Triplic ay}i�Application is hereby made to San Joaquin County for a permit to construct and/or install the work herei de�dr'►Yd.Tt� cJoaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulation um unty <br /> Job Address J � %J '} L' `5 7-rx/+3 V <br /> ��•dF' ✓'r-P Ciry Lot Si a/Ac re.a /C= <br /> Owner's Name fl-Ti, •/�,.,7 t,r e' Address 5etnE' Phone <br /> C. i55Z,'— <br /> Contractor`T�LL'AC3f> a -Se-1 Address /!1/X ��SyY �ie-c�" License No. AJc'C'y Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION b out of Service Veil 0 <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER O Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK ��C�' SEWER LINES DISPOSAL FLO. '— PROP. LINE = <br /> FOUNDATION �� r AGRICULTURE WELL — OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> E <br /> 0 Industrial pen Bottom ❑ Manteca Dia. of Well Excavation J Dia. of Well Casing QC <br /> P.i'I)omestic/Private ❑ Gravel Pack - ❑ Tracy Type of Casing_ .'ere-"4 Specifications <br /> a,s I'1 P,rblic I'1 Other fl Delta Depth of Grout Seal �,c- Type of Grout rt.5eelsA cyk <br /> 1 1 Im J / <br /> ation t'A // ,,a2 <br /> g� �� Approx. Depth I 1 Eastern Surface Soul Installed by=� <br /> Repair Work Done ❑ Type of Pump .5i46 H.P. -22 State Work Done _ ^ <br /> Well Destruction O Well Diameter Sealing Material L Depth \V <br /> Depth _ Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is �4 <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other I" <br /> Number of units: _ Number of Mdrooms <br /> Character of soil to ooh of feet: Water table det <br /> SEPTIC TANK O Tyq/AI} Capacity __No. Com`p-PbAy <br /> ME <br /> ` PKG. TREATMENT PLT.❑ - Method ofNT <br /> Distance to nearest: Well ation. Property Line sTC{i VL.'p <br /> LEACHING LINE Ll No. 6 Length of lines Total Ian a SAN ip4Ajj,0r\ <br /> FILTER BED 0 Distance to merest: -"Wall Foundation ProperHt,U O M SQRVIGE$ <br /> ne 'l l <br /> ` SEEPAGE PITS 1 pth -—Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws. and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the peiformance of the work for which this permit is issued, I shall not <br /> employ any person in such mannar as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies 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 <br /> tion laws of California." 9 <br /> The applicant must all for all required nspections. Complete drawing on reverse d . <br /> Signed x ,4 /L— Title: I '7 Date: S� '�3 'Ci•/ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by rev� lj/ Date If <br /> Z Area Z �� <br /> Pit or,Groyt Inspection by T� DatUL�/ l Final Inspection by _ Data <br /> Additional Comments: <br /> A plic6M Return all copies to: San Joaquin County Public Health Services �3b✓D_5 a D ' TN �p(S- <br /> ���jjj---,,, Environmental Health PermiVServices LLjj 3 R0 S(2.G03I3I — Tt� V —�D l <br /> ` � � 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95FEE I <br /> 20Y 0388 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. �_ <br /> L N <br /> .Tse tsar leev.vealA yrsrj n>1t -`. %7�.' .,: / ._���..� a <br />