ARCHIVED REPORTS_XR0007892 - Laserfiche WebLink

Home Browse Search

' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 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 i32' ��WoWr � Z City Lot Size/Acreage Owner's Name VC { MiSSrIS�`(( � Address � Phone s110 a �Iru 2.�—L8 G- c.[C�'e�'>r Z71,a g C? 4 7 l Contractor '� Address , y _ License No Phone TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT 7 DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well ta+ DISTANCE TO NEAREST SEPTIC TANK SEWER LINES _506 0' _ DISPOSAL FLD POOP LINE FOUNDATION b AGRICULTURE WELL OTHER WELL—10" PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS— 44' L] industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia of Well Casing Cl Domestic/Private X Gravel Pack7 ❑ Tracy Type of Casing 5ci1•TIyG _ Specifications ' i 1 Public f"] Other n Delta Depth of Grout Seal Type of Grout I 1 Irn{faUonMpAtrApprox Depth >4 Eastern Surface Seise Installed by Repair Work Done U ype of Pump H P State Work Done Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet I Installation will sena Residence_ Commercial_ Other Number of Irving units Number of bedrooms Character of sort to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No Compartments PKG TREATMENT PLT ❑ Method of Disposal Distance to nearest Well Foundation Property Line LEACHING LINE Ci No & Length of Imes Total length/size FILTER BED ❑ Distance to nearest Well Foundation Property Line 1 SEEPAGE PITS 11 Depth Sire Number SUMPS Ll Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this appiicaaon 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 sub-contracting 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 must call to uir&5 inspections Complete drawing on reverse side �, Signed Title �lar 45sw_skr t Date 3Ait( 3 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments Applicant -- Return all copies to San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH a RECEIVED BY DATE PERMIT NO �Em 13-24 iREV o/n sa EM 14 26