Laserfiche WebLink
API'LTCATION SCANNED <br /> r �U SAN JOAQUIN CO' ONTY PUBLIC HEALTH SE VI # <br /> E}�IV�,ONMENTAL HEALTH DIVISION <br /> _ -:4451�•$AN JOAQUIN, PHONE(209)469-3 <br /> t =1'"O BqX 388,STOCKTON,CA 95201-038 <br /> r f✓I F s t, + , °, � r <br /> T EMIRES I YEAR FROM DATE <br /> (Complete in Triplicate) r'.',sll # {� <br /> �r <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. is application is made in compliance with San <br /> Joaquin County Development Title <br /> TiSection 94110.3 and Section 9-1115.3 and the Rules and Regulatioris of San Joaquin County Public Health Services. <br /> Job Address _ �G�(? _t>1- City Lot bite/Acreage . <br /> s'Y l l _a L[_bba I Phone ` <br /> Owner's Name � � ... Address <br /> Contractor & t +I <br /> N Address icense Na, 2 Phon <br /> TYPE OF WELLIPUMP: NEW WELLLXK. WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well [l <br /> PUMP INSTALLATION 0 SYSTEM REP IR ❑ 1 OTHER 0 Monitoring Well 0 <br /> _ DISTANCE TO NEAREST: SEPTIC TANK �f SEWER LINES DISPOSAL FLP. PROP. LINE <br /> FOUNOdT10�1 AGRICULTUAt WELL _ - t TH ft WELL f17$/SUMPS^� <br /> INTENDED USE TYPE OF WELL f ROBLEM AREA cONSTRUCTibN S0ECIFICATI6N6 <br /> �e <br /> C1 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation pis, of Well Casing <br /> t_ppmastiolPrivaiarsval Pack ❑ Tracy Type of Casing_.•- ••� Specifications <br /> i`1 Public Cl Other n Delta Depth of Gtoui Seal 0 Type of Grout <br /> !-I Irriliation 3w pprox. Depth 1.1 Eastern Surface Soul Initalled by <br /> Repair Work Done U Type of Pump H.P. 9W4 Work Doni <br /> Wall Dastnitaion 0 Wall.Diameter Sealing Material A Artpth <br /> Depth Spv„� liber Material i_bepth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION !I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted it public sower is <br /> available within 200 toot.) <br /> Installation will serve: Residence____ Commercial Other ' <br /> Number of living.units: Number of bedrooms' <br /> Character of 60H to a depth of 3 fist: Water tlibti depth <br /> ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartmenta <br /> PKG. TREATMENT PLT. ❑ Ale b <br /> Distance to nearest: Weil Foundation Props 1I�y�F <br /> t �-{ <br /> LEACHING LINE Cl No. b Length of lines Total longih* <br /> I FILTER BED Il Distance to nearest: Well Fovnoation lCkrJU <br /> iV 111 <br /> �V JUI4MIN ('00111 V <br /> SEEPAGE PITS I I Depth sire <br /> SUMPS # Ll Distance to,nearest, Well -Foundition Property Lina <br />' DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sen Joaquin county ordinances, state laws, and <br /> rules and regulations of the Sari Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that In the performance of the work lot which this permit is issued, I shalt not <br /> employ any person in such manner as to become subject to workman's compensation laws of California," Contrictor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the pirformance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- <br /> tion laws of Califorhia." <br /> The applicant muff'calf for all required Inspections. Complete drawing o raver ode. <br /> Signed Title: LVV% Data: 'r <br /> FOR DEPARTMENT USE ONLY <br /> Application Acceptid by nr - Date <br /> Arai <br /> Pit or Grout Inspection by r Dater( O Final Inspection by Data <br /> Additional Comments: aAl�d r SJ•,ti a [ l �! ",..we c( C".c, ~/� <br /> Applicant Return ail copies toe San Joaquin al Heal Public it/Seri Services <br /> Environmental Health Permit/Services (• <br /> �3 r 445 N.San Joaquin;P.O.Boz 388,Stockton,CA 95201-0388 <br /> �INFEE 0 AMOUNT DUE AMOUNT pEMITTED CASH RECEIVED by DATE pERMIT'N0. M <br /> EH 13:24 otty,1iRSi q,o ' ✓1f/ ✓ V *�f" J y 1 ✓ ! a <br /> EH 14.26 <br />