SU0003456 - Laserfiche WebLink

Home Browse Search

i APPLICATION I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ry ENVIRONMENTAL HEALTH DIVISION !r I 445 N SAN JOAQUIN,PHONE(209)469-3420 i P 0 BOX 388,STOCKTON,CA 95201-038$ COPY PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ryII (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work heroin described.This application is made in compliance with San Joaquin County Development Title Section 9-1110.3 and Sectio 9-11115`.3 and the Rules and Regulations of San Joaquin County Public Health Services. . Job.Address � p� 20�� I PC?`y t Size/Acreage ,d�l1 gni Q 1 " ner's Name Q GL I`�i? CNf Address ll /S� �Gz Z 1 _ — Phone f-31— 424 7 * y Contractor LL.• -.Glw% S Address �`' t2 „rf,q License No. 23 �„�Phone t.-.TY.PE Of SHELL/PUMP: :NEW WELL WELL REPLACEMENT DESTRUCTION WDut of eervici Will Q j }PUMP INSTALLATION Xe-- SYSTEM_ REPAIR ❑ OTHER ❑ Monit4rinq Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTWRIE WELL tige, OT-HER,WELL - PITS/SUMPS } INTENDED_ USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS II ; _ L7 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. 01 Wall Casing I- Cl Domestic/Private , Wi Gravel Pack El Tracy Type of Casing �A- Specifications rt 1'1 Public 1-1 Other 171 Delta Depth of Grout Seal too T pe o1 Giou I iSatiOn _Approx. Depth i0lastern Surface Soul Installed by Repair Work Done 0"' Type of PumpV. [)%VVJ H.P. State Work Done Well Destruction U]/ Well Diameter rr Sealing Material i Depth EI Depth Piller Material i Depth7 I ' TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is u hp, available within 200 feet.) Installation will serve: Residence T; C mmercial_ Other Number of living units: 'Number of rooms I` Character of soil to a depth of 3kfeet: Water table depth SEPTIC TANK O Type/Mfg.. Capacity No. Compartments PKG:"TREATMENT PLT. ❑ �" �' . Mettwd,of_Disposal ' p k i Distance to nearest: We Foundation Property Line LEACHING LINE L No."� Length of lines Total length/size FILTER BED ❑ Distance to nearest: all Foundation Property Line J: SEEPAGE PITS 11 DepiFr Site Number APR T 7 1995 .r SUMPS L"1 Distance tonear t: Well Foun tion Property Li DISPOSAL PONDS ❑ II ! YA�tC0UN7Y I hereby certify that I hove prepared this application and that the work will be done in accordance with 'Attlftn "f'At[ �tni99sol , and rules and regulations of the San Joaquin County Home owner or lica a nt's signature eenifies the following: "I certify that iri the performance of the work for which this permit is issued, I shall not employ any per n in such ' Inner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signiture certifies the owing:owing: "I c itify that in the performance t a work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws f Calif �io i The app cantfar 1 rempiet rawmg on r a side. QM!�, Signed /`dt-✓ Ti;le; Date: 4-13 FOR DEPARTMENT USE ONLY Application Accepted by M" Date Ar �I Pit o'i� Inspection by Final Inspection b Data Additional Comments: t{v �r✓1Z` j 7�9 Applicant.- e es to, San Joaquin County Public Health Services �--6A� �f} - A, Environmental Health Permit/Services a v�" "7 °"`9-S�tVV1, 445 N.San Joaquin,P.O.Boz 388,Stockton,CA 95201- 388u „Qpa ,��Guf q INFO OUNT DUE AMOUNT REMITTED ASH RECEIVED BY OAT E"iiM+OD k raEVI l� D �r7�$ O� ? Q i r �J. 1 �40 i