ARCHIVED REPORTS_XR0008826 - Laserfiche WebLink

Home Browse Search

' AIJI)LIC t I'l ON PAYMENT SAN JOAQUIN COUNTY PU13LIC HEALTH SERVICES ENV I IIONMENTAL HEALTH DIVISION RECEIVED 445 N SAN JOAQUIN , PHONE (209)468--3420 FEB 16 1993 P O BOX 2009 , STOCKTON , CA 95201 SAN JOAQUIN COUNTY PERMIT EXPIRES 1 YEAR FROM DATE- ISSUED PUBLIC HEALTH SERVICES (Complete in Triplicate) ENVIRONMENTAL HEALTH nIVISION ' Application le hereby made to San Joaquin Courity Cor a permit Lo construct and/or install the work herein described. This applicatlea is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules "4 Regulations of San J"quf<n counter rr'uYlile health Serrvileeee. /r /� Job Address %fJQ WU(/_P/-/V O [i ___ _____ ___ City g2:_ ' o 1 Lot Size/Acreage _ 0, ' Owner a Name 7el9 6e!'g4 fw/Addiuss �'d0 �0� Phone r Contractor Address /X -10 52 LrCense No C2yr10fY.,ZPhone ' TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR C1 OTHER 19 S0�igsibtor ng Well L7 DISTANCE TO NEAREST SEPTIC TANK /l/,4 SEWER LINES, DISPOSAL FLO PROP LINE ' FOUNDATION AGRICULTURE WELL &/ OTHER WELL 3-S0' PETS/SUMPS .� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 177 Industrial ❑ Open Bottom C3 Manteca Dra of Well Excavation Dia of Well Casing ' f 1 Dornessic/Private ❑ Gravel Pack i) Tracy Type of Casing- Specifications I I Pubtic A Other f`1 Delta Depth of Grout Seal 7� � Type of Grout p�L?��• S �SScr:u7"-s 1 1 IrnOauon 7-E7Appror, Depth I I Eastern Surface Soul Installed by ' Repair Work Done Ll Type of Pump H P State Work Done Wall Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material i Depth 0YPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 lest i Installation will serve Residence ._.,_, Commercial_ Other Number of living units Number of bedrooms ' Character of &ON to a depth of 3 lest Water table depth SEPTIC TANK ❑ Type/MIg Capacity No Compartments PKG TREATMENT PLT ❑ Method of Disposal Distance to nearest Well Foundation Property Line ' LEACHfNG LINE ❑ No 8 Length of lines Total length/size FILTER BED n Distance to nearest Wall Foundation Properly Line ' SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest Well Foundation Property Line ' DISPOSAL PONDS ❑ 1 hereby candy that 1 have prepared this application and that tha work will be done in accordance with San Joaquin county ordinances, state laws, and rules and fegulallons of the Sen Joaquin County Home owner or licensed agent's signature cenlfies the lollowing 'I candy that in the parlormance of the work for which this permit Is Issued, I shall not ' employ any poison in such manner •s 10 become subject to workman *compensation laws of California Contractor'*hiring or sub contracting signature certifies the following "I certify that in the performance of the work for which this permit Is issued, 1 shall employ persons subject to workman's compensa lion laws of California " The applicant must calf for all required inspections Complete drawing on reverse side Signed X Title 5A-Z.,4 Data FOR DEPARTMENT USE ONLY 1 Application Accepted by"', Date +j �r Area 1 r Il or Grout Inspection by 1 / Dais Final Inspection by Dais ditionai Comrnonta ' Applicant - Return all copies to San Joaquin County Public health Servlr.us Lav415 N Sono JoIluaquin. P Permit200U, Stk 4f5 N San Jonyuin, 1� O [lox 2004, 3tkn, CA 9520lFEE � ' NINFO AMOUNT DUE AMOUNT REMITTED _ ICK if f RECEI1iVtfo BY DATE PERMIT NO EHf3IREV ii�er FH Ir