Laserfiche WebLink
w. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PMWIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 28300 CARTER City ESCALON Lot Size/Acreage- <br /> Owner's Name VILLA DEVELOAMENT Address P .O. BOX 477 Phone886-5673 <br /> Contractor HENNINGS BROS. DRILL.Address 3525 PELANDALE AVE.License No. 290813 Phone 545-1185 <br /> r TYPE OF WELL/PUMP: NEW WELLYa WELL REPLACEMENT C❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> t DISTANCE TO NEAREST: SEPTIC TANK 100 , SEWER LINES 1001 DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSu <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Wetl Casing 6 rr <br /> FX Domestic/Private I Gravel Pack L7 Tracy Type of Casing PVC Specifications0 <br /> I"I Public M Other n Delta Depth of Grout Seal 10 0 1 Type of Graut BENTONITE ' <br /> 1 1 Ifrioation -7-0�5.Approx. Depth I I Eastern Surface Seal Installed by H F N N I N G S R R 0 S. D R I L L I N G CO. <br /> Repair Work Done U Type of Pump H.P, State Work Dane, <br /> Well Destruction ❑ Well Diameter Sealing-Material & Depth <br /> Depth Filler Material & Depth <br /> 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.l <br /> Installation will server Residence— Commercial T Other <br /> Number of living units: Number of bedrooms _ <br /> Character of soil to a depth of 3-feet:'- Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Wel! Foundation Property Line <br /> t <br /> f LEACHING LINE D No. & Length of lines Total length/site <br /> FILTER BED EI Distance to nearest: Well " {Foundation Property Line r <br /> SEEPAGE PITS 11 Depth Size Number - <br /> ', SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> rules and regulations of the San Joaquin County <br /> 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, t shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> ! 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- <br /> tion laws of California." <br /> } The applicant must call for all required inspections. Complete drawing on r verse side. <br /> 4 Signed X Ttle. Date: SEPT. 3 0,—. 19 9 2 <br /> F DEPAR MENT USEONLY <br /> Accepted by Date Area47 <br /> ! Pit o Grout nspection by Date Final Inspection by Date <br /> I � t <br /> Additional Comments: -Liel <br /> t Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> INFq Ck <br /> AMO/U�NT DUE AMOUNT REMITTED `�C SH RECEIVED BY DATE PERMIT NO. <br /> EH 1924IREV.rix S]VV IV 6)4 i t� . GNU 1 ,//3 9 <br /> EH 14.26 C <br />