ARCHIVED REPORTS_XR0007742 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PBRHIT SAN JOAQUIN CQUNTY PUBLIC HEALTH SERVICES Q ENV IRONIMTAL H$ALTH �209 �468-3 C�(Q S 445 N SAN JDAQIIIN, PHON 420 P O BOX 2009, STOCK—,—CX PERMIT—WIRES 1 YEAR _DRQ_ DATES 5��17 W r 3 9? 2 (Complete in Triplicate) Applicatlon 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 vith San Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 2. job � JobAddresa fv� r `°t* _ City�`r Lot Size/Acreage Owner's Nome fu FI k JIL100• Address LAKC- AA5A 901U,��AK F.". Phone 31 96 j HJT-(-Eir.-+_r� + sr-� c Contractor WC-:— 1 ,-7� I P �`' i 11. ("Address %� � �- -"1�►�' �� -�� License No �4 Phone ! �" TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT C7I DESTRUCTION 90 Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 0 HER 6 Monitoring Well ❑ DISTANCE TO NEAREST SEPTIC TANK I SEWER LINES - _ DISPOSAL FLD If '' PROP LINE —Lj2— FOUNDATION `�} AGRICULTURE WELL rI OTHER WELL26-2 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Die of Well Excavation Drs of Well Casing C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I 1 Public n Other 1"l Delta Depth of Grout Seat Type of Grout I I Irrigation —Approx Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H P State Work Done Sealing Materiel i Depth �f Wail Destruction L� Well Diameter � ` Depth S Tiller Material i Depth + A .TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l 1 lNo septic system permitted if public sewer is evadable within 200 fast 1 Instailatwn will serve Residence— Commercial— Other Number of Irving unite Number of bedrooms Chwactw of soli to a depth of 3 lest 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 ❑ No & Length of lines Total length/size FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS 11 Depth Sue Number SUMPS LI Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby comity that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances state laws, and rules and reguletrons of the San Joaquin County Home owner or licensed agent's orgnaiure cenifres 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 Camillo"the following "I certify that in the pedormanee of the work for which this permit is issued, I shall employ persons subject to workman a compenss tion laws of California " The appbcs st tall r cared inspections Complete drawing on reverse side ` i Signed Title P��-Z �'ar r ; 'IF�'N ,.t* 1 S feta � f i J f! mz �% OR DEPARTMENT USE ONLY1ZApplication Accepted by Date Arae Pit or Grout Inspection by Date Final Inspection by Date lkdhional 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 AMOUNT DUE AMOUNT REMITTED K 9 RECEIVED BY DATE PERMIT NO INFO /�CAS�}H �j-y . EM 13 24 titEV i/m s) �� y {J�G t� I 6I� 7 4 EH 14 2fi