4710 - Laserfiche WebLink

Metadata

Thumbnails

Annotations

't APPLICATION t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ,L Lv�E ENVIRONMENTAL HEALTH DIVISION �� 445 N SAN JOAQUIN,PHONE(209)469-3420 P O BOX 388, STOCKTON,CA 95201-0388 r -33.3 a 1l0" PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete ;in Triplicate) ,, 3 1 001 -234 N _.. Application is hereby made to San Joaquin County far a permit to construct and/or install the work herein described.This application is made in compliance with San i . t Joaquin County Development Titl n 9-1114.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Publ�c�ealth Services. r1 City Lot Size/Acreage Job Address Phone O er's Name Address 1 ` Q55 t'.c S r�ddres /!' �.Incoln] cense No. 3Gto7Z hone" JSa�YC Contractor TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Out of Service Well G ' - PUMP I ' 'SYSTEM SYSTEM REPAIR 12t OTHER ❑ Monitoring Well D DISTANCE TO NEAREST; SEPTIC TANK- SEWER LINES DISPOSAL FLD, PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED US E TYPE OF WELL PROBLEM.AREA CONSTRUCTION SPECIFICATIONS NS- C] Industrial i ❑ Open Bottom G Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private 0 Gravel Pack ElTracy Type of Casing_ Specifications I-1 Other Cl Delia r Depth of Grout Seal Type of Grout— 11 1"1 Public t ;.£ 1 , i I Approx.1 — Depth l I Eastern Surface Seal installed by tnigation ' Repair Work Done U. Type of Pump H p• State Work Done +I 'Sealing Msterlal i"Depth Well Destruction ar Well Diameter / Depth � t a •tZ PA-IF filler Materiali DepthTYPE OF SEPTIC WOflK: NEW INSTALLATION i I R /ADDiTIQN I I DESTRUCTION t I (Noave septic system permitted if public rower is ' available within 200 faet.l I Installation will serve: Residence Commercial _ ^ Other ' a T Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth F i-..SEPTIC TANK O Type/Mfg Capacity i No. Compartments PKG. TREATMENT-PLT. ❑ Method of Disposal � Distance to nearast:"T Wel! _,._ Foundation Property Line PAYMENT REGEIVES LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED" G Distance to nearest: Well Foundation Property Line �k�N�y I r SAN )OA kJIN C __ Number Pk.1HLiC HEAL H S1�FiVICF:S SEEPAGE PITS . I I Depth Size SUMPS Ll -Distance to nearest: Well Foundation Property Lins fff DISPOSAL PONDS O i 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 a rules and regulations of the San Joaquin County shall not Home owner or licensed agent's signature certifies the following: "I certify that in the periormance of the work for which this permit is issued, I shall employ any peram dn in such anner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature, certifies the followings"I Certify that in the performance of the work for which this permit is Issued, I shall employ persons subject to workman's compansa-�^ ktion laws of California." The applicant ust 11 for all r i inspections. Complete drawing on reverse fide. �L�J _ Title: Date: Signed X, r . k. i FOR DEPARTMENT USE ONLY 7. Date Area_2- j Application Accepted by T ' Final Inspection by Date �_ ��,,,,t/J ' Pit or Grout Inspection by Date * Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services i t Environmental Health Permit/Services 445 N:San Joaquin,P.O.Boz 388,Stockton,CA 95201 0388 �} a t i t FEE" AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMII""N0. i M_ INFO cn EK 1 -IoH �-24 IREV.1/n SI fK to-;* �,