92-2965 - Laserfiche WebLink

Home Browse Search

•tf ��. ti APPLICATION FOR PERMIT SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 t (209) 468-3447 PERMIT EXPIRES 1 YEAR 1fRQX 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 vi.th San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public yHealth Services. e� Job Address 7-ol �(1Q</7rAM� City 0"Cy Lot Site/Acreage /0A-,Le.X Owner's Name 4S5PA14/01 � Address �„S/d n� _ Phone �v 493Vo i Conitactos. ecncbp 4 -.a '.Address License No.S/zAGB Phone 4s, 197/4 l I TYPE OF WELL/PUMP, NEW WELL $) WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well Cl PUMP INSTALLATION C SYSTEM REPAIR 0 OTHER 0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK>106 PC SEWER LINES >1$V Fr DISPOSAL FLD.X •0 PROP. LINE �FT FOUNDATION 1 S 4 AGRICULTURE WELL &•*POTHER WELL :nF7_ PtTS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r 0 Industrial C3Open Bottom 0 Manteca Dia. of Well Excavation pia. of Well Casing S/o U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing. STS/rvGest /per-- Specificationsd//�f`�IB4 . M Public C3 Other ❑ Delta Depth of Grout Seal —S'�Cr Type of Groutyc�r�dar M Irri alion �f� �Swnwr�. /Cts g •�.Appro,r. 06pth fl Eastern Surface Seal Installed by Repair Work Done U Type of Pump II H.P. State Work Done_ Well Destruction O Well Diameter �_Vlw Sealing Material & Depth 4;4j^-Alewl*r OM Depth fT Filler Material 4 Depth 021/G Srtti►„p_Fwn B Ts 71cx"T ' l TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION M (No septic system permitted it public sewer is I I available within 200 feet.) Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK C1 Typo/Mfg f Capacity No. Cam- _t,4 7 PKG. TREATMENT PLT.0 Method oi:Di Distance to nearest: Well Foundation Property Line ' 3R., LEACHING LINE ❑ No. 8 Length of lines Total length/size - °< FILTER BED n Distance to nearest: Well Fon fl _ r -�•"i = Foundation Propert�l #'s .ie :_-�, -•�,, ",��; SEEPAGE PITS II Depth I Site Number SUMPS U Distance to nearest: Well Foundation Property Line (b ' DISPOSAL PONDS ❑ I 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 bec6me subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature n I 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 applies $I call for all required )ns Stions. Complete drawing on reverse side. Signed r• r� Title: Jae r.-crDate: i FOR DEPARTMENT USE ONLY 5T2�7 Application Accepted by Date �� •�� Ar C/ I Pit or Grout In `7'I f!' f Inspection by Date q Fina! Inspection by pate i ff Additional Comments: t Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STUCKTON, CA 95201 FEE INFO MOUNT DUE � AMOUNT AEMIT7El) sr CASH RECEIVED 9Y DATE PERMIT N0. . EH 13,24;AEV.,/w3, �V �✓ d3'T�J L1'26•i1 S •L�(�v� M EN'�•7e 'tJ