SU0004390 - Laserfiche WebLink

Home Browse Search

yLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION " 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 9520111 ..`, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ppllcatlon is hereby =de.to San Joaquin County for a permit to construct and/or install the work herein described. This pplicatlon is aside in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San osquin County Public�• CAL) Services. l �1 )b Address -7 r 'Wn ' .1 City QT95D Lot Size/Acreage wneis Name � ' k�lPOVI� Address �bq7 k(Ol '4_146 AW -S-rh::� Phone —4;o2- �I � $2a✓6 ontiactor ALF Address. S,r-1 License No. Phone ,. tPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT C1 DESTRUCTION U Out of Service Well ❑ PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ STANCE 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 Well Excavation Dia. of Well Casing Domestic./Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Public 1-1 Other n Delta Depth of Grout Seal Type of Grout Irrigation _Approx. Depth 11 Eastern Surface Seal Installed by pair Work Dora U Type of Pump �u.rlaL,I a H.P. L,v.(C State Work Done :QS-411 y.,. nC-. all Destruction ❑ Well Diameter Sealing Material L Depth � �n G/ . Depth Tiller Material i Depth .0 'PE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public Anwar is available within 200 feat.) msullation will ssrW: Avoidance_ Commercial_ Other Vumber of living uni Number of bedrooms 2haracter of IoM to a depth o Water salol h- PTIC TANK ❑ Type/Mfg Capacity o. Compartments P G. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Property Line 4CHING LINE ❑ No. 8 Length of line Total length al .TER BED ❑ Distance to net: WNI Foundation Property Lina EPAGE PITS Depth Size Number MPS LI Distance to rwmt: Well Foundation Property Lina iPOSAL PONDS ❑ Irony certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and is and regulations of the San Joaquin County ' ma 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 ploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature lilies 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 componss. I lawn of California." I applicant at call for all required inspections Complete drawing on reverse side. nsa V.A/ GL o Title: Date: 0,3 f-Z-- FOR FOR DEPARTMENT USE ONLY Aicatfon Accepted by Oats 3Z�b Area or Grout Inspsctlon by Date Final Inspection by -GGC_O Data * .-d 12-- litional Comitants: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, O Box 2009, Stkn, CA 95201 FEE INFO AM tNT DUE AMOUNT REMITTED 4A RECEIVED 0Y DATE QPERMITTIN.O...� &�P77 .� ".3 /(�/ CJc/ lO .Y/ QL 2--36JV