ARCHIVED REPORTS XR0012794 - Laserfiche WebLink

Home Browse Search

APPLICATION SOJOAQUIN COUNTY PUBLIC HEAL SERVICES ^r " ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM 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 with San Joaquin County Ordinance No 5149 and 1662 and the Rules and Regulatiene of San Joaquin County Public Health Services Job Address c�J� l'iC/V. f�a�7/N T ? City Lot bize/Acreage k/Chti k '=A,14 7 _ Owner s Name �L- /�✓ /�- - Address Al At!lruU 1_,;`] c^ice /Zi3i7 , Phone L!Ie-i✓Ji`7Z/-//A//y-Y./iC ice' .LSe--I-D License No - Phone '65,2 - 1-Y7%/ TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring Well DISTANCE TO NEAREST SEPTIC TANK SEWER LINES � �?` / DISPOSAL FLD PROP LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS twdusuul/��N�� ❑1 Open Bottom ❑ Manteca Dia of Well Excavation Ora of Welt Casing G C I Domestic/Private �I Gravel Pack* 0 Tracy Type of Casing_ �1/ � 5 // - fir- �/tC!Specihcauons I I Public I 1 Olher 'pt Delta Depth of Grout Seat J / Z� er- y Type of Groutlff.�i i I trrigdtlon -3Q Approx Depth I I Eastern Surface Sent Installed by r Repair Work Done U Type of Pump H P State Work Done , Well Destruction ❑ Well Diameter Sealing Material L Depth Depth Tiller Material L Depth T F SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo seplic system permuted if public sower}sl- available within 200 feet I Installation will Residence_ Commercial _ Other Number of living units Number of bedrooms Character o1 wil to a depth of 3 feet or table depth SEPTIC TANK ❑ Type/Mfg Capacity No Compartments PKG TREATMENT PLT ❑ Method of Disposal Distanee to nearest :::�� �etron Property Line - — LEACHtNG LINE C1"No-3 Length—of lines length/size FILTER BED ❑ Distance to st Well Foundation Pro Line SEEPAGE PITS Depth Size Number SUMPS LI Distance to nearest Weil Foundation Property Line 0 AL 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 Horne owner or licensed agent s signature certifies the following I Certify that in the performance of the work tar 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 foflowing I certify that in tha performance of the work for which this permit is issued I shall employ persons subject to workman s compensa tion laws of California " The applicant u Il forvlaall1l required inspections Completel�d[raawiinl on r v se side Signed ' /n t t 11 'f] +��-1 Date ? + 1 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Addrtlonal Comments 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 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED By DATE PERMIT NO Ell I3-24(RIEV 1/K 51 EM 14 20