90-2650 - Laserfiche WebLink

Home Browse Search

f APPLICATION FOR PERMIT r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION k P O BOX 2009, STOCKTON, CA 95201 '+ (209) 468-3447 { PERMIT EXPIRES 1 YES PRM DATE I5SUED i (Complete III Triplicate) k 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 owwliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San t Joaquin County Public Health Services. II Jab Ad 4904 W Mueller Rd Cit� kn - ___ Lot Size/Acreage +1 00 a_crpS.__ E t� r Owner's Name Klein Ranch Address PO Box95201 Phone 481 —8342 Contractor Clark Well, .!Inc Address 2024 E. Charter License N0.371560 Phone46 7676 TYPE OF WELL/PUMP: NEW WELL 13 WELL REPLACEMENXXX DESTRUCTIOW(R Out of Service Well 0 PUMP INST;ALLATIOWEX SYSTEM REPAIR 0 OTHER O Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK *.7 r, SEWER LINES DISPOSAL FLD• PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k Ll Industrial O Open Bottom 0 Manteca Die. of Wall Excavation 1 tf r r _ Die, of Well Casing " �^ r - Domestic/Private }Gravel Pack n Tracy Type of Casing Specilication M Public I 1 Other ^1 X)p Delta Depth of Grout Seal _ 301 Type of Grout M Irrigation ^.Apprax. Depth ❑ Esslarn Surface Seal Installed by. i14Rt;1l_l - - Repair Work Done U Type of Pump _- et H.P. _ -- State Work Done .� Weil Destruction ❑ Well Diameter Sealing Material i Depth Depth — Filler Material i Depth o 011l t0 top bentonite TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION 0 DESTRUCTION M !No septic system permitted if public sewer is available within 200 lest.} Installation will serve: Residence A Commercial_ Other Number of living Unita: Number of bedrooms Character of#oil to a depth of 3 fent: Water table depth ' SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT.EY Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. A Length of lines Total length/size FILTER BED n Distance to nearest: a Well Foundation Property Line .:1 SEEPAGE PITS 11 Depth f Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 become subject to workman's compensation laws of California." Contractor's hiring or sub-Contracting signature certifies the following: IcartiJ#4MV04e4jths mr1ofmance of the work for which this permit is issued, t shall employ persons subject to workman's compensa- tion laws of California." The applicant Ifo reins s. Ca to drawing on reverse side'. i Signs- Title: Dete:2 Or-.t A FOR DEPARTMENT USE ONLY �7 0-? Application Accepted by / Date Area Pit or Grout Inspection by Date `� ~P Final Inspection b Data6" v Additional Comments: Applicant - Return 911fcopies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES BG G l g 9 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES f' � 25 � d � 445 N SAN JOAQUIN, P 0 BOK 2008, STOCKTON, CA $5201 �� r EEE MO NT DUE: AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT'NO. INFO CASK , J I / QQ. o • EHt]•24IREV.simsf lir ib�#