SR0002742 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PEP -MIT SAN JOAQUIN COUNTY PUUBLIC HEALTH S S ENVIRONMENTAL HEALTH DIVI � k P O BOX 2009, STOCKTON, CA (209) 468— 34ZU (Complete in Triplicate "''��` Application Ss hereby made,to San Joaquin County for a permit to construct and/ install"the work 4 in described. application is made in compliance with San Joaquin County Ordinance No. 549 and 1e362 and the Rules and Regulations Of Joaquin County Public Health Services. ,pnl (4q— 210 —01 Job Address 800 f� MA /tI -ST City STOC>eTOA)_ Lot Size/Acreage Owner's NameA1qDt2Er,t) 1J-1DU1C.F 6y/}-c-(A�ddress P•o•aDX 8123 SToszTb/J Phone 94B- 3040/' RA"c 14-117 Contractor zA�wLt'-�'" Address •4• l30 2231 CceDQUA, '?5'741 License No.G724! 7 PhoneAff- 9SS8 TYPE OF WELL/PfJMPi NEW WELL O WELL REPLACEMENT P DESTRUCTION ❑ Out of Service Well ❑ �J PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER Monitoring Well [1 DISTANCE TO NEAREST: SEPTIC TANKSEWER SEWER LINES --S DISPOSAL FLD..t//� PROP. LINE -�_ 1` FOUNDATION —r AGRICULTURE WELL N�A.__ OTHER WELLPITS/SUMPS YZ4 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ],�iN� 17 Industrial ❑Open Bottom ❑Manteca Dia. of Weil Excavation '� ✓ Dia. of►el C sing f� Domestic/ Private 0 Public MI IrrtUaUon Repair Work Done L3 Well Destruction ❑ YPE OF SEPTIC WORK 0 Gravel Pack ❑ Tracy Type of Casing__MCA-'r Specifications KOther ❑ Delta Depth of Grout Seal �uQF�Type of Grout �451/ Approx. Depth C1 Eastern Surface Seal Installed by _CoN�AC7_11z ,(��J Type of Pump H, P. __ State Work Done _ Well Diameter _ Sealing Material i Depth Depth Filler Material i Depth _ _ PAYMENT NEW INSTALLATION D REPAIRIADDITION CI DESTRUCTION CI No septic syste sewer is Installation will serve: Residence _ Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ available w thine MAR 1FI Q11AR her _ 3r 1 191304 •,t .SAN J9Q.0!_I!N (,01JN7Y Capacity Distance to nearest: Well Foundation LEACHING LINE 0 No. & Length of lines FILTER BED (_.) Distance to nearest: Well SEEPAGE PITS I I Depth _Sire SUMPS L! r=istance to nsarsst: Well DISPOSAL PONDS ❑ NcE('A"@Id1e "taA Method of Disposal Property Line Total length/size__ Foundation Property Line Fou„dwion Number P: oporty Lin& I hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin county ordinances, slate laws, an 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 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 California." The applicsnt�jmus call f r all required inspections. Complete drawing on reverse side. Signed Title: �vtilr�raivt Date: FOQ. A DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspection by _ Date Final Inspection by _ Date s Additional Comments: L _I� Tb * I� Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HkALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICE fj O b O� J 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, C 95201 f\ EH 17.24 IREV. t/A 51 EH :1.20 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECErVEO BY DATE PERMIT NO. 'Sic)