SITE HISTORY - Laserfiche WebLink

Home Browse Search

APPLICATION SANYOAQUIN COUNTY PUBLIC HTALTHQ$RVICBS ENVIRONMENTAL HEALTH DIVISION . 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance with San-Joequin County Ordinance No. 549 and 1862 and the Rules and Regulations of San } Joaquin County Public Health Services. I Job Address 170 Z Jr�C_kSf) fq 61 Y26>gr City 6 c�- N Loot Size/Acreagel 3 D K 100 Owner's Name H-0 Address toO t fa.,OX 7 f.. �t-O!J J63ZO Phone Contractor se6n24 V1 1 AnQ dress ASS E • MYM5 sr 5 License No.5 f 22,ra 2 - Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Weii ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER OTHER ❑ Monitoring Well. - k 2V DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. PROP. LINE 5� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS H W IS Vapor we I's f/ F C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f b Dia. of Well Casing 41 n Domestic/Private ❑ Gravel Peck ❑ Tracy Type of Casing ISG VC. Specifications Rd ['I Public n Other n Delta Depth of Grout Sea[ Gp 3 r Type of Grout.Ne Lt-Ce ne4"f I I Irrigation _Approx. Depth I I Eastern Surface Soul Installed by M E l_[]e ATZA r7s CA oa-i Repair Work Done U Type of Pump N.P. State Work Done, Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Piller Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIWADDITION I I DESTRUCTION I I INo septic system stied if public sewer is available wit feet.) Installation will serve: Residence_ Commercial_ Other G Number of living units. Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg pecity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal (' Distance to nearest: Well Foundation Property Line 1� LEACHING LINE Cl No. 3 Length a s Total length/size I q I FILTER BED ❑ Distance nearest: Well Foundation Property Line SEEPAGE PLONDS Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOS ❑ 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 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 is.-cued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m call for all required - do . om drawing on reverse side. q Signed 791 Title: .CA- Z(2 �NO.Z 3 Date: 5 `f L� p� FO DEPARTMENT USE ONLY Application Accepted by i�jy Date /�s A Crea Pit or Grout Inspection by Date Final Inspection by � PLETFD Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services D Environmental Health Permit/Services J 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT /JDUE AMOUNT REMITTED CK if CASH RECEIVED SY DATE G� _RMIT'NO. PE . EN t3.24 MEY.rinse a�9_0 g�•VO .71 14 !/ t9-2 � #H 14.21 ii ' d