SITE HISTORY - Laserfiche WebLink

Home Browse Search

APPLICATION i SAN JOAQUIN COUNTY PUBLIC HEALTH'SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-3420 P O BOX 388,STOCKTON,CA 95201-0388 PERMIT R IRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) - Application is hereby made to San Joaquin Count for a it to construct and/or Joaquin County Development Title Section 9-1110.3 and Secti n 9-1115.3 and the Rules land Regulations of San Joaquin CountytioPub!c Health Serythe work herein described.This apn is made in c1es. With San Job Address 1-70 arc �3 CityE�V� Lot Size/Acreage Owner's Name J�r�- � �✓t:-/ Lf"O//'�'1 Address es a� / � �/k.� ell, phone ContractorMl 4Gf�Y1I Y Address Ap BO1C ZZ3J an icense No.(L?��a�7 _ Phone /0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well ❑ ,: PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE m FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing c3' ne� D Domestic/Private l CGravel Pack ❑ Tracy Type of Casing_ Specifications Il Public C1 Other n Delta Depth of Grout Seat -1/0to Type of Grout ation I I Irri t1 SQ Approx. Depth I 1 Eastern Surface Soul installed by 177rt4t.9CDP Repair Work Done 0 Type of Pump H.P. tate Wor Done Well Destruction ❑ Well Diameter Sealing Material i Depth d51 SZA-Q, AW Depth, Filler Material i Depth SJ 1 _V," ' 04e, -,-0-,11 W TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I QESTRUCTION I 1 INo septic system permitted it public sewer is available within 200 feet.) Installation ' serve: Residence— Commercial Other Number of livin Number of bedrooms Character of soil to a de 3 feet: ter table depth SEPTIC TANK ❑ T Capacity No. Compenrnents PKG. TREATMENT PLT. ❑ Method of Disposal w Distance to nearest: Well ndation Property Lina LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 1-3 Distance to near Well Foundation. Property Line SEEPAGE PITS I I Size Number SUMPS Distance to nearest: Wall Foundation Property Lin l DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinance , tela laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature " cenifiss the following: 1 cern that in the performance of the work for which this " certify permit is issued, 1 shall employ persona subject to workman's compansa- tion laws of California." The appl nust call for all required inspections. Complete drawing on ruts side. Signed Title: - Y /`/ Date ` 4 FO DEPARTMENT USE ONLY [�]1 Application Accepted by vl� Date + 77 Area Pit or Grout inspection by Date ./- Finst Inspection by Date n Additional Comments: Applicant -`Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N.San Joaquin,P.O.Boz 388,Stockton,CA 95201-0388FEE vim`•' v^ INFO MOUNT DUE AMOUNT REMITTED CK If CASH I RECEIVED BY DATE PERMiT'NO- k6ir '/7Z WEM 7,��]6 co . EH 13-21 rrety,i i s1 v 1-'� 4 VJ (�/7 a EH 1t-�