FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

mm0— PPUCATION FOR PERMIT WESTERN GEO-ENGINEERS QUIN LOCAL HEALTH DISTRICT Reystered Geologists HAZELTON AVE., STOCKTON, CA (916) 662-4541 Telephone (209) 466-6781 Jad E Npp,, Geurge i ConuerseVerM Mrp PIRES 1 YEAR FROM DATE ISSUED �If�)OLLi�n 1386 (. Bnxeer SL. , B1. a1, Box 111. Woodyi, CA 91695 (Man ofke) (Complete in Triplicate) �- YAM CA. (916) 213.?M6 District for a permit to construct and/or install the work herein described. P o. eox 59. C*k" CA "932, (Bolt. 9"0 Bad) (916) 45N159 549 for sewage or No.1862 for well/ This application is pump and the Rules and Reguladons of the San Joaquin Job Address3�N_ 100, / City_l�� Lot Size - PM Owner's Name **Al !�'1��+_ Address S,2r !au -sr mf�m Phone Contractor &rte 45094R.4TJea/ Address V!� X9[0y &616ra License No. 4801902- Phone ( lb TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIO ❑ SYSTEM REPAIR ❑ OTHER ft DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES —/�[ DISPOSAL FLD.�� PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of WeN Excavation <f Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing A(&A, Specifications ❑ Public VAftn ® Other ❑ Delta Depth of Grout Seal NV14 Type of Grout ❑ Irrigation isrt,a,L --Approx. Depth ❑ Easter Surface Seal Installed by '• Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction fig Well Diameter 4I�r Sealing Material(top 50'1 RFmTeaiPc - 466At tEfrE.0 t �T yev Depth —Hol 1 Filler Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) In ion will serve: Residence_- Commercial_ Other Number of i units: Number of bedrooms Character of soo to th of 3 feet: er table depth SEPTIC TANK ❑ f Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: 1 ndation Property Line LEACHING LINE ❑ No. & Length of lin Total length/size FILTER BED ❑ Distance t rest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line D AL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, rules and regulations of the San Joaquin Local Health District. 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 persona subject to workman's compensa- tion laws of California." The applicant must call for all required in actions. Complete drawing on reverse side.. Signed X—C• t'' a _ Title: Date: [Ie�`/D1�1�1` D PA M E ONLY 456 SiJT,�k/ �i/(►�V f Fp .6,? Application Accepted by Date__.`L;Z 3 �� Area Ph or Grout In o y Date Final Inspection by -C,�) �f�� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354MM Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT N0. EH 13-24(fifV.1 i 8 5) G Q EH 11-28 J