SU0014666 - Laserfiche WebLink

Home Browse Search

APPLICATION cD (�J/l S tin � y js`+i SAN JUAQUIN COUNTY PUDLIC A�. RVICES ENVIRONMENTAL HEALTH yak S0 445 N SAN JOAQUIN, PHONE ( Q)64&3420 P 0 AOR 2009, STOCKTON, (�i� 01_ PERMIT R ' ' I YEAR FRO � (Complete in Tripil Application is hereby made to San Joaquin County .'or a permit to construct and/or Install the work herein described. Th;s appllcat:on is mads in compliance with San Joaquin :minty Ordinance No. 549 and 1862 and the Rules axil Regulations of Pan Joaquin County Public Health Services. A Job Address k^'9 3 S$$_Jr� R _ Q C-rv �_ Lot //Size/Acreage t0 r'G 'r C� i Owner'.Hamt-f a _ o r`rnlrtij To m-e-S — Address _�'rrtte_ Phone Contractor L4cG �64IItJ` Address-106rC (v Sar License No.(e6_ TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT Fl DESTRUCTION Ll O—LProng ut of Service Mall ❑ PUMP INSTALLATION C SYSTEM REPAIR 7 OTHER ❑ Monitoring Well ❑ s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PP.OP. LINE ^ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industnal ❑Open Bottom ❑Manteca Dim of Well Excavation Dia.of Wail Casing (')Domestic/Private ❑ Gravel Pack -0 Tracy---------Type or Casing_ Specifications I'I Public I"l Other Il 06114 Coplh of Grout Seal Type of Grout In I I Imustion Approx.Depth I I Eastern Surface Soul Installed by Repair Work Done U Type of Pump - 1t P-----' _ Stats Work Dolt _Stallng Xisterial t Depth Destruction ❑ Well Dlamott` Dopth_-____��,^^_^,_- Filler Material L Depth i TYPE OF SEPTIC WORK: NEW INST LLATI1?.;-,REPAIRIADDITION OE-STRUCTION I I Ileo septic s sum f '� Y permitted rl public fewer i3 ` �Iavailable within 200 feel.I r� ` r lniulfatbn�w.g1 airy.?`iiosidenuCommercial_ Ouler r Number of!lying canna; i� Number of bedrooms t 't I 1 Character of&a to a depth of 3 fast: AY)6i,- ' Wales table depth ` �x� SEPTIC TANKType/Mfg 4, L G01%,C- r-F-4- Capacity 1. 15 t o e t • D No.-Compsrtnionts PKC.TREATMENT PLT.❑ r F I Method of _ Olp_ osal Distance to nosiest: Well Property y Line.�pf i �. LEACHING LINE 2e No.&Length of lines - Q of length/ala i FILTER BED ❑ 'Distance to nearest: (Q Foundation i N/ Property line _ t I ! SEEPAGE PITS 11 !DepthSize — Number t - SUMPSLI Distance to nearest Well Foundation Property Line i DISPOSAL PONDS ❑ ' I I �,1lareby comity that I have prepared this application and that the work will bo done to sccordm`a with San Joaquin County ordinances,state iows,and a rules and regulations of the San Joaquin County a _ I+c + t lti i Homs owner licensed agent's signature certifies the following:"I certify that in the peAormon a of the work for which this permit is is uod,I shall net (f employ any parson in such manner as w become subject to workman's compensation 4iV%of C16lornia."Contractors hiring or,sub-eontraetinj signature 1 f. ,unNisa the following:"I certify that in the performance of the work for yrhich this permit it issued�I shall employ persons eutjact to wwkman's Cortport" fI tkon.lows of Callfom4." }1! TAe'applicant must call for all r wired a;»ctions.Compiete drawing on reverts side. r------•� .11 i .Signed X Titov _ Darts. + i•-_... FOR DEPARTMENT USE ONLY _ Applieatbn Accepted by ��0 1�J7�� Q L Date =t" r PN of Grout Inalosetbn by Dau Final Inspection by Date �yc. i`:`•`L r AddMonal Comments. Applicant - Return all coplon to: San Joaquin County NI-A is Health Services bavironmentai Health rarslt/Service. - I. �.'�= r•- •.�,j _ 445 N San Joaquin, P 0 Box 2009, Stkn, CA 93201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED!v M ' INFO CASH DATE ►ERMIT'N0. s IN 13}14(AIV.via, ... i,..