SU0004896 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT :nw F= SAN JOAQUIN COUNTY PUBLIC HEALTH MVICES �� Z ENVIRONMENTAL HEALTH DIVISION J 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application in hereby mode to San Joaquin County for a permit to construct and/or install the work herein described. This application it code in compliance with San Joaquin County Ordinance No. $49 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 14`�y RC>92) City 5J= %CA1 Lot Size/Acreage Owner's Namel lS rl L'x�TAI G Address 1Y'd1&2JRV 4Lkg)alF Phone Contractor 'JST F �t71Lu,�(,— Address ! R O//fC" aKCCE S',`ITE cense No.. 9Uz,Q Phon 75-96 TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER *�, Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK .r�!SD SEWER LINES -7 � DISPOSAL FLO,Ala- PROP. LINE FOUNDATION Z„>' AGRICULTURE WELL -&LIL_ OTHER WELL ) PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial D Open Bottom ❑ Manteca Die. of Well Excavation /0" Dia. of Well Casing L<Domaatic/Private I51'GOVei Pack ❑ Tracy Type of Casing- Lar y PYr'. Specifications 1 1 1 Public In Other n Delta Depth of Grout Seal �.3 r Type of Grout MEAT('F_H<'+_`.T I i Irrigation %)— Appox. Depth I I Eastern Surface Seal Installed by �B S F_ a Repair Work Done D Type of Pump hi A, H.P. A/{1 State Work Done _ Well Destruction ❑ Well Diameter 1`1, Sealing Material i Depth .}W ]4�ti1ib1:17 e' Depth Filler Material i Depth .skZ ,54nB� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will wove: Residence _ Commercial_ Other Number of living units: _ Number of bedrooms Character of viii to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity PKG. TREATMENT PLT. D 71 , Well Foundation Prope ,DOQIlk LEACHING LINE ❑ No. i Length of lines Total IeGmsjwl - FILTER BED ❑ Distance to nearest: Well ouncation P etri EAI T:4 cr�Uwlr r$ -----EVIRONMENTAL H SEEPAGE PITS 1 I Depth Sire Number SUMPS LI Dista rest: Wall Foundation Property Line DISPOSAL 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, and rules and regulations of the Son 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 "if 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 followirq: "I csrtity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensr tion laws of California.- The appbcant must call for all wired i peclions. Complete drawing on reverse side. Signed Title: Date: 10-7-53 Gr�Kr•[ACE�TF/L f.taSX. /.✓�- _ OR DEPARTMENT USE ONLY Application Accepted by ,� Data Area Pit or Grout Inspection by Z� Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services LLa v/ �L(O Environmental Health Permit/Services c 445 N San Joaquin, P O Boz 2009, Stkn, CA 95201 INFO AMOVNT DUE AMOUNT REMITTED CASH RECEIVED 0Y DATE PERMIT NO. . IN3-14 uEv.11,s1 Er I4.Ie czO a