SR0003309 - Laserfiche WebLink

Home Browse Search

APPLICATION 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) &Ib�4 ovHaa9 Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application 1s made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. --7�� Job Address 2-364 &ST ��iC�b City MAU-, Lot Size/Acreage 'A AGS PEZT'ArJA '�Mii K'(�,('I� �D AWG DfF+(�i A'7 -11 Owner's Name Address Esta �IVb CAMAL d> VD 1�CX[bNPhon�2pq) r474— 194 Contractor t)&� � � 6 TYPE OF WELL/PUMP DISTANCE TO NEAREST: INTENDED USE n Industrial C I Domestic/ Private F] Public I I Irrigation Repair Work Done 0 Well Destruction ❑ Address 106;_4 j)Ij J7 A&, NktA`ELicense No. bJ736& Phone NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION, SYSTEM REPAIR L]BOTHER ❑ Monitoring Well SEPTIC TANK (ND6' SEWER LINES lo DISPOSAL FLD. IA PROP. LINE 7 FOUNDATION btAGRICULTURE WELL OTHER WELL Zit PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r�/ E) Open Bottom ❑ Manteca Dia. of Well Excavation y Dia. of Well Casing (l ❑ Gravel Pack Tracy Type of Casing _itlMP atn'f Vv Specifications I1 Other &W06 W 171 Delta Depth of Grout Seal �AC 41' Type of Grout 10m;* agy- - Approx. Depth I I Eastern Surface Seal Installed by L Type of Pump (' H.P. _ S tg�Wolk one Ir Well Diameter Sealing Materiel ii Depth �k"7M i1 Depth O Filler Material 6 Depth/ �-I't`c 'P-> PTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK O Type/Mfg PKG. TREATMENT PLT. 0 Other Water table depth _ Capacity No. Compartments Distance to nearest: Well Foundation LEACHING LINE Ll No. & Length of lines _ FILTER BED ❑ Distance to nearest: Well Foundation SEEPAGE PITS I I Depth Size SUMPS LI Distance to nearest: Well DISPOSAL PONDS ❑ Foundation Method of Disposal Property Line Total length/size_ Property Line Number Property Line 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 I 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 Califor Ia." The appli nt m c�l inr al u red inspections. Complete drawing on reverse side. p Signed X �� Title: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Additional Comments: Date Final Inape ion b Date Applicant - Ret r 11 copies' to: Ssrn 5oaquin County Public Health Servi Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, EH 13.24 (REV. rix 5 EH 71.26 es CA 952<� ov 30 501 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO.