SU0003078 - Laserfiche WebLink

Home Browse Search

9 � � iszv -5(200v �,� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 q 3WO - 36)S" AV, P O BOX 2009, STOCKTON, CA 95201 431,�O- � J� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This epplication Is made in compliance with San Joaquin County Ordinance No. 549 18§2--sad ReAulstlons of San .Joaquin County Public Health Services. lob Address Z 5 y 5 a E 4 OV e City E5 �O►i r. �t bd_ 91ze/Ac�tage Owner's Name SOD n Towner Address __ /54PIe Phone 6-95-3339 Contractor art i n PUM Address -ee KO-444 icense No.36 _:: Phone - 031 y TYPE OF WELL/PUMP: NEW WELL 21f WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitorial Well DISTANCE TO NEAREST: SEPTIC TANK f 1* SEWER LINES l 001+ DISPOSAL FLD. PROP. LINE ��^ I FOUNDATION � AGRICULTURE WELL OTHER WELL PITS/SUMPS 1�0 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS If 1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 16749M Dia. of Well Casing ` W Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_.__ Specifications - Public [-1 z1 Other n Delta Depth of Grout Seat �� Type of Grout �Dn 1+t- ii Irnllauon Z/ Approx. Depth I I Eastern Surface Seal Installed by Reoe;r Work Done U Type of Pump _41JVn H.P. '3_ State Work Done _ ^, 'JVell Destruction O Well Diameter Sealing Material i Depth _ Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence ____ Commercial_ Other _ Number of living unit_: Number of bedrooms Character of soil to a depth of 3 feet: _.. Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well __._ Foundation Property Line LEACHING LINE L1 No. b Length of lines _ Total length/size FILTER BED Cl Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS 11 Depth Size .._—_— Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 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 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 CplifO711&+ -- The applicant rrus y all for all requir Ins 1' ns. Complete wing on reverse side. Signed X _ Title: CJ ( Date: _ r _ FOR DEPARTMENT USE ONLY Application Accepted by Date Area Au— ff Pit or Grout nspection by 1' Uat ��s Final Inspection by Date Additional Comments: / `_ `" _`�( _ (Ir r Applinant - Return all Lpies to: San .Joaquin County Public Health Services LX Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 6 ) , l4� FEE ' AMOUNT DUEAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. \\ INFO � 1rnJ 9. ty0 n ] jj g 93 -�s.t5 EM 13 24 1REV.1, r f'` S LJ(1 /�� , G'�.� "� / 7.J �t✓ /� FH ?a