Laserfiche WebLink
!* APPLICATION FOR FERMI-_ <br /> i, <br /> SAN JOAQUINI COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION l <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA. 95 REAMIT R YE R FR PT <br /> (Complete a.at Triplicate) —t- <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein•d'es'scsib&.' This <br /> application is made in 0=911ance vith San Joaquin County Ordinance No. 549 and 1$$2 and the Rules and Regttlstione of San <br /> Joaquin County Public: Health Services. <br /> Job Address_ 5400 EAs+ H-qim - City LOW: Lo Size/Acreage <br /> Owner's Name O of- 20t ✓1{.;, Adid ress 5400 Ea + 4r 4OMp, Phones 0 <br /> � <br /> A' (� 'I'iw <br /> Contractor s"E '�,�- ,,.- Address ?0!1 BUX I U4 W. AC. CA icense No.0 S511118 Phone alb 373 It t <br /> TYPE OF WEt LtPUMP: NEW WELL WELL REPLACEMENT DESTRUCTION 0 Out of Service hell C1 <br /> PUMP INSTALLATION CI �� SYSTEM REPAIR Q OTHER O Monitoring Wel] <br /> DISTANCE TO NEAREST: SEPTIC TANK Zoc> EA SEWER LINES , DISPOSAL FLO. � A PROP. LINE <br /> FOUNDATION 1 t, AGRICULTURE OTHEf3 WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR06LEM AREA CONSTRUCTION SPECIFICATIONS It <br /> CI Industrial Q Open Bottom © Manteca Dia. of Well Excavation 113 Dia. of Wee Casing <br /> n Domosiic/Pr'tvaut Gravel Pack 0 Tracy Type of Casing : 5,1ti PVC. Speciticatlons <br /> ('I Public 1.1 Other M Delta � Depth of Grout Seth 38:Lf Typo of Grouf <br /> t a trri0atrort _Approx. Depth I I Eastern Surfige Seal Installed by -1 r <br /> Repair Work Gone CI Type of Pump P/A }3-.P: $tate Work Clone._ <br /> well Destruction Q Wsb Dietl tar N Sealing rial t Depth f3 -64 "' �• riii'4 � <br />�., Depth ' {y0 IFIller Material i Depth n�ro. -t I est k)O. 15 Movsrw� , * <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I 1 REPAIRIADOITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br />!! A available within 200 feet.) <br /> i <br /> Installation Residence_ Commercial ": other _ <br /> h � _ <br /><< <br /> Number of fiving units: Number of bedrooms >- <br /> Charactetr of soil to a depth of 3 �YV fs depth <br /> SEPTIC TANK. 0 Typeimf9 <br /> Capacityi# <br /> i No.Compartments <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest: Well' Found Property Line <br /> 3-I <br /> LEACHING; LINE CI No.3 Length of lines Total length/size <br /> FILTER BED Q Distance t est: Well foundation Property Line <br /> it <br /> SEEPAGE PITS t Depth Size Number <br /> r <br /> t SUMPS L.l D'rsunceto nearest: Vtlelt Foundation , Property Line <br /> 1 DISP L PONDS D <br /> I hereby certify that I he"prepared this application and that.the;work will be done in accordance with San Joaquin county ordinances,state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent`s signature certifies the following:"1 certify that in the performance of the work for which this permit is issued.l shall not <br /> employ any person in such manner rs to become subject to v kmen's compensation laws of California."Contractees hiring or sub-contracting signature <br /> certifies the following:"I C"fy;that in the or of the'V"for which this ploy persons subject to watkmart's compensa <br /> P! e Permit is issued,l shall em <br /> tWr1#$w3-of California." <br />".. <br /> The s plicant J t� ! r uiremtpeccr e,tirawing on reverse side. <br /> oil 44 <br /> t <br /> S 4 4/Lt _- -- Date, <br /> Ig r;t itle: ial INAM <br /> .a g <br /> t Ir DEPARTMENT USE ONLY <br /> Application Accepted by ( Date _ Area <br /> Ph or 0104Inspectlort by Data- Final Ina coon by Dots <br /> II l r <br /> Additional Comtrnants: W L fT <br /> y <br /> App2leaaL —'Return a21 copier i<os Jbnqi <br /> uia County Public Health <br /> Services, Ftavironme:atal Health Pertait/Services <br /> 2602 <br /> Z. Raze:ltoa Ave., P 0 Box 2009, Stockton, CA 95201 <br /> ANFO AMOUNT DUE AMOUNT ftElvgMO G Sts RECEIVED By DATE PEftw-N4. <br /> . EN 13-24lakv.sinal V 3 nf9 �7t) j <br /> Etc:076 07 1..�u 4I � l,tl JQi <br />