SU0006032 SSNL - Laserfiche WebLink

Home Browse Search

APDL (-a"1'1L)a SAN JOAQUIN COUNTY PUBLIC HEALTH ( ESVIC`�S/-� ENVIRONMERTAL HEALTH DIVISI #flY 9 gP740 445 N SAN JOAQUIN, PHONE (209)4E8-3/�2 P O BOX 2009, STOCKTON, CA 9 2FAC # PERMIT EXPIRES 1 YEAR FROM DATE ItAth J0 // a (Complete in Triplicate) Application is hereby sade,to San Joaquin County for a permit to construct and/or install the work herein described. This application is smde in coa@liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address O �ryN�b�Y� City zy_4 Size/Acreage d'�v- v Owner's Name r90'/f'1K dress Phone / 77 //� � Contractor Address License Nt�` _ � Phone TYPE OF WELL/PUMP: NEN WELL ❑ WELL REPLACEMENT Cl DESTRUCTION CI Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well LT 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 SPECIFICATION�A ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �CC"(Vq�2��!��1..6fNJel1 Casing -11 f7 Domestic/Private ❑ Gravel Pack n Tracy Type of Casing_— I'I Public ❑ Other n Delta Depth of Grout Seal MAY 9fh994 Grout _ 1 I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by IN UUN Repair Work Done U Type of Pump H.P.- Sta(i�Zr" Y V^ as Wall Destruction ❑ Well Diameter Sealing Material A Depth QN /� Depth Filler Material 0 Depth TYPE OF SEPTIC WORK! NEW INSTALLATION Liff REPAIR/ADDITION 1 I DESTRUCTION ] ) (No septic system permitted if public sewer is available within 200 feet.) t Installation will serve: Residence L� Commercial_7 Other _ Number of living units: _/ Number of bedrooms .3 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Pit Capacity�.� No. Compartments PKG. TREATMENT PLT. ❑ Method of Dispos91 Distance to nearest: Well /004- Foundation , 3 0 Property Line A LEACHING LINE ❑ No. 8 Length of lines Total length/size A FILTER BED ❑ Distance to neares y Well Foundation Property Lina !)—_0 ` t7 VU r SEEPAGE PITS 11 Depth Sire I/ l�2- 3 isn _—Number L�� SUMPS LI Distance to nearest: Well Foundation.� Property Line . !EI --"'— 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, and 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: "I certify that in the performance of the work for which this permit is issued. I shall employ persons subject to workman's compensa- tion laws of California." _ The applicant Inust call f 11 uued inspections _o eta drawing on reverse side. Gr l�91V 44 Signed K Title: `-�: Date: Y FOR DEPARTMENT USE ONLY / Applica r/,/t/�Acceprod by /r/�/t7`'�C.�fA syT_iL� Date ^Iq Z( L 'l z' L"irtiu2 Ins tion by-1�,-9 U e ')- `7 Final Inspection by / 1.2 ',<1 C Date ;L Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services / II Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 INF AMO/VNT DUE AMOUNT REMITTED R H R IVED BY DATE PEP MITI NO. EM 13 14 IREV. .EM 1&A I L (!