Laserfiche WebLink
1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT---- IRE 1 FROM DATE ISSUED, <br /> t (Complete in Triplicate) <br /> Application is hereby made;to San Joaquin County for a permit to construct and/or install the work he described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and. the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 30299 Hall Rd.,i CityEscalon Lot Size/Acreage <br /> Owner's Name Allen Ter stra Address '5043 Tully Rd. , Modesto Phone 545—3 353 <br /> Contractor Larsen Pumps, IncAdd(ess509 Tully, Modesto License No276660Phone529-2020 <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ ! <br /> PUMP-INSTALLATION fX SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br />�..� -DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -DISPOSAL FLD. _ r PROP-LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i <br /> IX Domestic/Private C1 Gravel Pack j ❑ Tracy Type of Casing_ Specifications <br /> I'I Public EI Other F1 Delta Depth of Grout Seal Type of Grout I <br /> 1 <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by d <br /> Repair Work Done U Type of Pump Sub H,P. 2 State Work Done Install system J.J <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth - <br /> Depth Piller Haterial i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial,-.` Other ° +� <br /> PAYM <br /> -Number of living units: Number of bedrooms ENII <br /> Character of sod to a depth of 3 feet: <br /> Water t i <br /> SEPTIC TANK. ❑ Type/Mfg 77-" Capacity No. Comport to <br /> PKG. TREATMENT PLT. ❑ -t Met hodli pe <br /> Distance to nearest: Well 1 ` Foundation Property Lim COU <br /> H�A�1H SERVICESI I jai IC , <br /> LEACHING LINE Cl No. b Length of lines Total length/ ionNMENTAI <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> .4 <br /> SEEPAGE PITS I I Depth Sire __ndNumber_ <br /> '-'LI�Di�unca to nearest: Well Fouation Proparry L_ine <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> rules and regulations of the San Joaquin County <br /> 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 <br /> a <br /> employ any person in such manner as to become subject to workman's compensation laves of California." Contractor's hiring or sub-contracting signature <br /> 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- <br /> tion laws of California. <br /> The applicant rcall for AN retWired inspections. Complete drawing on reverse side. <br /> Signed Title: Sec. , Tres. Date: 3/26/93 f <br /> F DEPA EN N <br /> Application Accepted by Date Area ,/ ) <br /> Pit or Grout Inspection by Date Final Inspection Date r <br /> r <br /> Additional Comments: <br /> • F <br /> Applicant -Return all copies to:- San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEEINFO AMOUNT DVE AMOUNT REMttTED C_CK RECEIVED BY DATE PERMIT'NO. <br /> 24+ <br /> :m <br /> 11.1!6 tllEv.fiK51 <br />