Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESk! +`�O <br /> ENVIRONMENTAL HTsALTH DIVISION Co nc o rA CA".k 4 10 <br /> 1601 E HAZSLTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> E,RXIT AXP RES, 1 YEAR FROM DATE 1100 <br /> r (Complete in Triplicate) <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described This <br /> application is leade in coWliance with San Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County public Health Services <br /> Job Address Z3? =r e` a DoQt-a'va, CITY �r'�C pLot tbize/Acreage <br /> Owner a Name v� ` pt 1 Cor Address gO0 /T�I•.....eir}• phore� ZGXP <br /> CA <br /> Contractor t-Lk* S} t'{atZs%"elk _ Aftess Z3�3 �� '� Cor icense No Phone 1 <br /> TYPE OF WELL/PUMP NEW WELL e WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well C1 <br /> RP e.%ow r y t-aea(i <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP UNE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation_ 12 Dia of Well Casing (� <br /> CeDom*slie/Private $T'ravel Pack racy Type of Casing V Specifications 91 <br /> 1 I Public I-1 Other n Delta Depth of Grout Seal y Type of Grout <br /> 1 I Irrrj)alron ___ Approi Depth I I Eastern Surface S6a1 Installed by L.2N s Kea ti"`a`} — lJ <br /> Repasr Work Done U Type of Pump HP Stat* Work Done r <br /> Wap Destruction ❑ Welt Diameter Sealing Material i Depth V <br /> Depth Filler Material E Depth - <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septw system pernulled it ptrhbc sever is ^ <br /> available within 200 feet 1 <br /> Installation wsn serve Residence — Commercial — Oth*r - <br /> Number of living units Number of bedrooms <br /> Character of sod to a depth of 3 feet Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No Compartments <br /> PKG TREATMENT PLT ❑ Method of Drspos it <br /> Distance to nearest Wen Foundation Property Line }, <br /> LEACHING LINE C1 No 8 Length of Imes Total length/sae <br /> FILTER BED 0 Distance to nearest Wen Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest Wen Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 /> ruses and regulations of the San Joaquin County <br /> Home owner or licensed agent s agnaiurs candies the following I cenify that in the performance of the wort for which this permit is issued 1 shall not <br /> employ any person in such manner as to become subject to workman s compensation laws of California Contractor s hiring or sub-conttacnng u9nature <br /> candies the fonowing 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 Caldorms " <br /> The applicant must can for an roqujrq0,inspections Complete drawing on reverse side <br /> r <br /> Signs '" ^ Title 5�•► �j Xtra\O t Z Date <br /> a�<rA�t- <br /> FOR DEPARTMENT 115E ONLY <br /> Application Accepted by 's' Date AWT Area <br /> Port or Grout Inspection by Date Final Inspection by Date <br /> Addlaw"l Comments <br /> �Applicarst — Return all copies to San Joaquin County Public Health SZyo� <br /> Services, >tavironesental Health PerwI it/Servlees / <br /> 1601 E Hazelton Ave P 0 Box 2009. Stockton. CA 95201 <br /> IFEE <br /> NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED by DATE PERMIT NO <br /> Etit 1,344 IREV i,a$r <br /> M is I � <br />