ARCHIVED REPORTS XR0000472 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH, SERVICES - - RU ,,�J ENVIRONMENTAL HEALTH DIVISIONS 445 N SAN JOAQUIN, PHONE (209)468-3420 (�,r �y1 L, i;c•.�i 1 5 1994 P O BOX 2009, STOCgTON, CA 95201 , <<`, I+, L'3 1,3 ' �ERMIT EXPIRES 1 YEA_R.FROM DATE ISSUED BrotYn & CZIdMlel (Complete -in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described This application is made in compliance with San Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations or`San Joaquin County Public Health Services. Job Address City S�C.�kf`�-•_ Lot Size/Acreage �• �rr'f v Fo 8 `c. Sfskl, _ Owner a Name IZc D �.oil...F C�«��..T Address �'h r''t��'�. Cry rl`f �- Phone{415 517-lf` lbr 3L4I - -- _= Contractor�4}r►1�= `,orx>fia _~Address I .,�I�i)� f �r�lu.i« . L•� rtS'lLLtcenseNo�Lc�L'tL[�µ Phon!`Ifr� xSz.-7-1��{ TYPE OF WELL/PUMP NEW WELL�' WELL REPLACEMENT n DESTRUCTION ❑ Out of Service dell ❑ PUMP INSTALLATION ❑ SYSTEM REP1UR C1 OTHER ! Monitoring well �s+ .u. t) ��i ..�..� Std r1 DISTANCE TO NEAREST SEPTIC TANK SEWER LINES i C�11 f SP SAL FLD PROP LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS W INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , n Industrial ❑ Opan Bottom ❑ Manteca Dia of Well Excavation "Sia of Well Casing (I Domestic/Private Cl Gravel Pack 0 Tracy _ _Type of Casing_ hU L- Specif tions I I Public-- - I 1 Other- - s- Delta Skxl''AD� Depth of Grout Seat ll.t<4u��L1 � ,Ja Type of Grout a I Irn aeon _Approx. Depth I I Eastern Surface Seal Installed by I—�cy- -ef Ert kc r_4 �w �Repast Work Pone -LJ Type of Pump Af2wIlt— - H°P - - State Work DonaWell_Des_tru_ction ❑ Well Diameter Sealing Material i Depth L.•v„} r, . Vca`r t�. ,z T Depth Filler Material & Depth wl TYPE OF lC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I fNo septic system permitted if public sewer is T available within 200 feet I Instillation will serve idence Commercial_ other Number of living units mber of bedrooms Character of sod to ■ depth of 3 feat Water table depth SEPTIC TANK _ ❑z TypelMfg Capacity No Compartments PKGTTREATMENT PLT ❑ Method of Disposal Distance to nearest Wall Foundation _.Property Lrna LEACHING UNE C1 No_&_Length of lines _Total langthisize - — FILTER BED ❑ Distance to nearest Well Foundation Property Lina SEEPAGE PITS 11 Depth Sue Num_be Y SUMPS Ll Distance to nearest Well Foundation Property DISPOSAL PONDS ❑ _ I hereby carlify 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 regulat4ans of the San Joaquin County Home owner or licensed agent s signature cenif es the following 'I certify that In the performance of the work for which this permit is issued I shall not --- ---employ any parson in such manner■s to become subject to workman a-compensamo� 4e 4_of Cal4fornia Contractors hiring— or�iL; contrectingiignature - 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 a compensa tion laws of California " The applicall must call for all required inspections Coom/pE to drag on favor" fide L Signed X d�1'1''° .,�,cC[.c T' � ro'�4� L.•e,�n {"S T- ' �7 1 2.,� y V ale Date �! {-" FOR DEPARTMENT USE ONLY y/t Application Accepted by Date f ' Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments Ap Applicant - Return all copies to San Joaquin County Public Health Services Environmental Health Permit/Services 448 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK d CASH RECEIVED 9Y DATE PERM17 NO 1H132411ltEV I/01 III qt5/ -1 � S � r a�� 3 -rr' 14 1435 �/