Laserfiche WebLink
APPLICATION FOR PEPWIT <br /> Sklll`�JOAQUIN COUNTY PUBLIC HEALTH S <br /> ENVIRONMENTAL HEALTH DIVI S <br /> �x <br /> P O BOX 2009, STOCKTON, CAS I� <br /> (209) 468- 3420 A&u <br /> (Complete in Triplicate N <br /> Application is hereby tends to Sea Joaquin County for a permit to construct and/ <br /> application is made in c�liance vith San Joaquin County Ordinance No. 549 and <br /> JoaQuia County Public Health Services. <br /> /a —o t <br /> Job Address 800 FMA i�l SAP.v 149- 2 <br /> T <br /> Owner's Name City STOCICTbAI Lot Size/acreage f�Z, _ <br /> /"tMe t2Fr� �J yn �F �.0.aDX cl7 3 <br /> Address y <br /> Phone q4,8_ 3 <br /> Contractor ��dress�0.130X 22�! 12avetam <br /> TYPE OF WELL/P MP: evr>o.re 9r 74 License No.G72G/ 7 Phone/ )I <br /> NEW WELL O WELL REPLACEMENT O <br /> ❑ <br /> PUMP INSTALLATION DESTRUCTION O Out of Service Well C.) Ln. <br /> SYSTEM REPAIR ❑ OTHER X Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK TI N f7 <br /> -�� SEWER LINES DISPOSAL r DISPOSAL FLD. a7rL S0¢/"/— <br /> FOUNDATION /S` AGRICULTURE WELIi✓ �1 ��- PROP. LINE _'S• <br /> INTENDED USE •-L— OTHER WELL,± PITS/SUMPS ��i1 <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �j <br /> C7 Intlustrial O Open Bottom IA! ��N� <br /> ❑ Manteca Ola. of Well Excavation "'� �`^ <br /> &Oomsstic/Private C) Gravel Pack Dia. of el C sing .1//� <br /> ❑ Tracy Type o1 Casin <br /> D Public Other B—_/Yovc specifications <br /> O Delta Depth of Grout Seat 15aa -GF <br /> Cl Irnpation �.Approx. Depth Type of Grout �rE <br /> Repair Work Done C] p O Eastern Surface Seal Installed by CO <br /> Type of Pump { <br /> H.P. <br /> Well <br /> Well DestructionState Work Done — <br /> O Diameter Sealing Material i Depth ^ <br /> Depth Filler Material i Depth t� <br /> TYPE Of SEPTIC WORK; NEW INSTALLATION JLJ REPAIR/ADDITION Ll DESTRUCTION G INo septic sysle r NT <br /> Installation will serve: Residence _ available wtthin ��YE V sewer is <br /> Commercial Ojher�— f <br /> Number of living units: Number of bedroomsMAR 3 1 1934 <br /> Character of soil to a depth of 3 feet: �` (�An <br /> SEPTIC TANK f ,, WatertyebA}eNdJritS;`'L)�nJ COUNTYO Type/Mfg <br /> PKG. TREATMENT PLT, Q Capacity_. NcEmiA@1�q@ptsAl , <br /> Distance to nearest: We)I Method of Disposal Z <br /> Foundation Property Line <br /> LEACHING LINE O No. 8 Length of lines <br /> FILTER BED () Distance to nearest; Well — Total length/size <br /> Foundation Property Line <br /> SEEPAGE PITS I I Depth — <br /> S+ze <br /> SUMPS LI Number <br /> Distance to nearest: Well ! <br /> DISPOSAL PONDS ❑ Foundation Props rf Lina U �' <br /> I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, andf <br /> rules and regulations of the San Joaquin County <br /> 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 <br /> employ any person in such manner as to become subj <br /> certifies the ow <br /> ect to workman's compensation laws Of California." Contractor's hiring or sub-contracting signature <br /> following: "t 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 <br /> Mu calf f r all required inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: eOAASa,ra.v� 1Z4�/9/i� <br /> Date; 3 <br /> FOR DEPARTMENT USE ONLY ` <br /> Application Accepted by <br /> Date 7 <br /> Pit or Grout Inspection by <br /> Date l !� Final Inspection by <br /> Additional Comments: — J Date <br /> L 10 n�L s <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC H ALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 9520 <br /> FEE <br /> I FO AMOUNT DUE AMOUNT REMITTED CK Jr <br /> C� <br /> CAS. RECEIVED By DATE <br /> PERMIT N0. J <br />