SR0003765 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420; >� `.L HE^AI_li1 P 0 BOX 2009, STOCKTON, CA 95201 - =''.f� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i; ;I (Complete in Triplicate) _ FI. Application is hereby made to Ban Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Be"iices. C _ I Job Address 1$21 E. MO -V -P -T ` T. City STDCV_TOfv bot Size/Acreage Owner's Name `�`� S (� jM�u' Address b =� MAP_y_Gj S� t13 Phone ``� I - U�'j- Contractor OSTsk?, L 2c, t Jt eww" Address PC7 41 P,I Ver Q 6Q, License No. `441616-70 Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION XOut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE rnttunAT111M AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE D Industrial (.l Domestic/ Private I'1 Public 1 I Irrigation Repair Work Done Well Destruction TYPE OF WELL O Open Bottom ❑ Gravel Pack 1-1 Other _ Approx. Depth U Type of Pump _ ❑ Well Diameter Depth PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Manteca Die. of Well Excavation Dia. of Well Casing ❑ Tracy Type of Casing_ Specifications n Delta Depth of Grout Seal Type of Grout I I Eastern Surface Soul Installed by H. P. State Work Done _ Sealing Material i Depth hJ F_ ArT CSJL4,q .►T /t1etta"J. 12 4 t - Tiller Material ti Depth F SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installat 11 serve: Residence _ Commercial _ Other Number of living un Number of bedrooms Character of "a to •depth of 3 e SEPTIC TANK O Type/Mfg PKG. TREATMENT PLT. ❑ Distance to nearest: LEACHING LINE Cl No. d gth of lines FILTER BED ❑ tante to nearest: Water table depth - No. Compartments Method of Disposal Property Line Total Well Foundation Property SEEPAGE PIT I I Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS u I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin county ordinances, state laws, and rules and regulations of the Sen Joaquin County Home owner or licensed agent's signature certifies rhe following: "I certify that in the performance of the work for which this permit is issued, I shell not employ any person in such manner as to beton» subject to workman's compensation laws of California." Contrsctor's hiring or subcontracting signature certifies the following: "I certify that In the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion taws of California." The applicants_c ad requk ns InspectioComplete drawing-owCP � Date: n reverse �si'de. I Sigma Title: -L)IL. • 1 _ G�/` �%� r / FOR DEPARTMENT USE ONLY Application Accepted by Data Area U c Gu.t1(s 9 Ph or Grout Inspection by n � � � � �Q ,I a e 1 �Fi�nal�Inapectlon by Date Additional Comments: � o Uv -(B C S f YI A �z tI-koa_l U_SL 1" 20 J Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 EH 1341 IREV. I/ AS EH 1448 FEE INFO AMOUNT DUE AMOUNT REMITTED K CASH RECEIVED By DATE PERMIT NO. '(�I G 0 3 1(D _j