90-1777 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ! SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FROM DA PsD (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This i application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Heal.th_Services. 7 D N 36 acres Joh Address � City Lot Size/Acreage Eddie Freggiaro Address same Phone 931 3188 Owner's Name Contractor Clark Well Address 2024 E. Charter License NoU-1-5-6-0—Phone - 2676 f TYPE OF WELL/PUMP: NEW WELD WELL REPLACEMENT 1- DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATIONC SYSTEM REPAIR D OTHER ❑ Monitoring Well f DISTANCE TO NEAREST: SEPTIC TANK1 00 r SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL j nor -_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 171 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1-2 r' Dia. of Well Casing tr � Type of Casing Specifications GL 16 0� Xk Domestic/Private �}2{Gravel Pack L7 Tracy YP 11 Public 1:1 Other n Delta Depth of Grout Seal 1 OO Type of Grout I I Irrigation Approx. Depth I l Eastern Surface Soul Installed by - _ Repair Work Done 0 Type of Pump Sub - H.P. 5 State Work Done.in St_a 1 1 _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION { I DESTRUCTION I 1 iNo ave septic system permitted i1 public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK. .❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal .Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED O Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ 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, an 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 subcontracting signature certifies the following: "Iify tl •n the rf/rma.nof the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of CaGfo ia.The applicant I f II re s mplete drawing on reverse side. Signed X Title: VP Clark Well Date: 1 1 7131V 90 O ARTMENT USE ONLY �y Application Accepted byovv Date_ L" << --...- Area -71h Pit or Grout Inspection by 1 Date Final Inspection by Date Additional Comments: �G I CSM I L 2-14 Ci2/If C "V( I_ Applicant - Return all copies to: San Joaquin County Public Health �_f l7tgz'd Services, Environmental Health Permit/Services I 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE MOVNT DtJE AMOUNT REMITTED CASH CK I RECEIVED BY DATE PERMIT'NO. t INFO r a EH 13-241REV.rfA51 i'D� I 7 EH 14.20