Laserfiche WebLink
SAN IN COUNTY PUBLIC HEALTH ICES <br />itUIRON11ENTAL HEALTH r <br />446 X SAN JOAQUIN, PHONE (209)468-3420 <br />P 0 BOX 20090 STOCKTONO CA 95201 Z) <br />PFMIT 1i♦IR95 1 YEAR FM DATE ISSUED <br />(Complete in Triplicate) <br />Application Is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br />Application to made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br />Joaquin County Public Health Services. <br />T__ 11 0000 C 111164-4- DA _ AAft_+-__M t -d 04.-/A ...... I M*7 <br />Job AMISS <br />ForwArd Inc. Address P.O. Box 6336 0 Stockton, CA96206Phone (209 Akk=5292- <br />Owner's Name <br />CA, 94303 <br />Ptcer <br />Contractor i h <br />_Phone(415)328 .1; <br />o Alto, License No. _afi3DJU -89 <br />Drng CO- Address _.E. O.Box5O367, Pall <br />Drilling <br />TYPE OF WELL/PUMP: <br />NEW WELL 0 WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well 0 <br />#(_ ,&We& C1 <br />PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER IjC . gn1totn <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.— PROP. LINE — <br />FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMPS <br />INTENDED USE <br />TYPE OF WELL PROBLEM AAEA_ CONSTRUCTION SPECIFICATIONS <br />n Industrial <br />0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br />17.1 Domestic/ Private <br />0 Gravel Packs0 Tracy Type of Casing- Specifications <br />Il Public <br />XX other 4 soii nDelts Depth of Grout Seal Type of Grout 22rtland g_W <br />I I Irrigation 100, 80, % ApprAP6JOS I I Eastern Surface Seal Installed by <br />Repair Work Done 0 <br />Type of Pump H. P. State Work Done <br />Well Destruction 0 <br />Will Disrhattr Sealing Material A; Depth <br />Depth Filler Material & Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br />available within 200 fest.1 <br />Installation vW11 Serve, <br />Residence — Commercial — Other <br />Number of living units: <br />— Number of bedrooms <br />Character of soli to a depth of 3 fast: —Water table depth <br />SEPTIC TANK <br />0 Type/Mfg Capacity— No. Compartments <br />PKG. TREATMENT PLT. <br />0 Method of Disposal <br />Distance to nearest- Well Foundation — Property Line <br />LEACHING LINE <br />0 No. A Length of lines 'total length/size <br />FILTER BED <br />0 Distance to nearest: Well Foundation — Property Lind <br />SEEPAGE PITS <br />11 Depth Size Number <br />SUMPS I <br />LI Distance to nabratt: Wall Foundation — Property Line <br />DISPOSAL PONDS <br />0 <br />I 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 licaftW agent'i Signature canifles 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 subject to workman's compensation laws of California." Contractor's hiring or Sub -contracting 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." <br />Application Accepted by <br />Pit or Grout Inspection by <br />Additional Comments: <br />'ttiOnt. Complete drawing on reverse side. <br />Title: Data: 0 <br />W <br />jo <br />,2� �-Y, MAPARTMIENT USE ONLY <br />Date — Final Inspection by <br />Applicant - Return all copies to: Sen Joaquin county Public Health Service$ <br />Savironmental Health Permit/Services <br />445 0 San Joaq0th, P 0 Box 2009, Stknj CA 95901 <br />1H 13*24 1"Ev.'1 /A 5 <br />EN 14.M <br />!nt <br />Are# ;Z 1-7 <br />Date SE" V <br />XZ_Z__ <br />A <br />A e. <br />Kan <br />