Laserfiche WebLink
t <br /> APPLICATION' <br /> SR U1N COUNTY PUBLIC \AT SERVICES <br /> SR �/ VIRONMENTAL HEALTHI-A <br /> ION <br /> AID # /��� P OXAN J22009, STOCKTON,UIN, PHONE (209 5201420 <br /> FAC # PERIL I` EXPIRES 1 YEAR FROM DATE [SSUED <br /> INV # �5u(e (Complete in Triplicate) <br /> —,A s ((/ oa uln County for a permit to construct and/or install the work herein described. This <br /> application Se me e a Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> / t_ <br /> Job Address <br /> -� �(�' - C k 1 l�-Y�_�� Gry _J1_ Lot Size/Acreage <br /> Owns 'a Name <br /> R- G Address U 'f C.�C'r. C" Phone <br /> Conti icto, V � I I ~� -� �..1 1�" Address . I-_ ? �r Phone Z C:-� 7 7c <br /> ci , , �t;d—1 '= `� License Nc�- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION ut Oof Service Well ❑ <br /> PUMP INSTALLATION El SYSTEM REPAIR [1 OTHER ❑ Monitoring Well <br /> DIST NCE TO NEAREST: SEPTIC TANK IC.GV', e. SEWER LINES _ DISPOSAL FLD. PROP. LINE,_S00 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> [l Inc strral El Open Bottom Ll Manteca Dia. of Well Excavation__I- Dia. of Well Casing <br /> [I Do esuc/Private ❑ Gravel Pack Ll Tracy Type of Casing ____-- Specifications <br /> I'I Pu lic 11 Other I1 Delta Depth of Grout Seal Type of Grout <br /> 11 Irlij aeon -_ Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 11 Type of Pump �� H.P. -___ Stat �Qrk DPr�e � <br /> Well estruction Well Diameter _ Sealing Material i Depth XC e rkC�� <br /> fl r <br /> Depth Ir y Filler Material i Depth e'r n -►^ 'U ��� f'L� <br /> P <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUC I0,Nyl iNo'y ic-syst9m_perirlitfWcj if public sewer is (Y <br /> availabl within 200 feet:Y <br /> Instillation will serve: R sidence _ ommericiel __ Other <br /> Nufy bar of living units: Numb6t Qf bedr-41 s _�_7F <br /> Cha actor of soil to a dIL <br /> th of 3 feet: —W�ter table depth <br /> SEP J TANK Type/Mfg �� Capacity NQ. table <br /> s",PK REATMENT PLT. Y;; i Methgd of Disposal <br /> ,} Distance to nearest: Well ( foundation PropnrtMgine <br /> i <br /> LEAd ING LINE No. & Length of lines — Total length/size _ <br /> FILfEF BED (I Distance to nearest Well _ Founaation --- Property Line <br /> I <br /> SE P E PITS 11 Depth Silo _— —_ Number <br /> SU 'P ' LI Distance to nearest: Well Foundation _ Property Line _ <br /> D11400 AL PONDS ❑ <br /> I her certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rgles� d regulations of the San Joaquin County <br /> Home weer 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 <br /> amplo any person in such manrler aWt become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> eertlfie the following: "I certify thtt ir�thtpe OFT"ante of the work for which this permit is issued, I shell employ persons subject to workman's compensa- <br /> tion Is s of California." J CX <br /> Thep llicant `i call fo all a 1rgInspec�s. (. m—oplete drawing on reverse side <br /> f <br /> Signed K \; �� Q�./1/l 1 >"� Title: <br /> 7Date:77 <br /> -' <br /> IFOR DEPARTMENT USE ONLY �� <br /> Applics ion Accepted by a _" - Date -� AreAare <br /> Pit [ Pt► rtibgl ITTsrsECtToTrby--.._-- <br /> Additio al Ade%tk- <br /> Ap <br /> )Ii - Return all copies to: San Joaquin County Public Health Services <br /> l Environmental Health Permit/Service:; <br /> �rra 445 N San Joaquin, P 0 [lox 2009, Stkn, CA 95201 <br /> FEE ANIOUNT DUE AMOUNT gMITTED _CK- RECEIVED BY DATE PERMIT NO. <br /> INFO CAS <br /> E. 13.24 IREv.r In a) <br /> EH <br />