Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN f0AQUIN COUNTY PUBLIC HEALTHNIIERVICES ylgx yz <br /> ENVIRONIfENTAL HFAT.TH DIVISION !� <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 M1 Y 3 1 1995 <br /> PERMIT EXPIRES- 1 YEAR FROM DATE ISSUIED ENVIRONMENTAL HEALTH <br /> (Complete in Triplicate) PERMR/SERVICES <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address Wgs 6ra-4t L stn P, Road--- City TracvLot SI ze/Acreages <br /> Owner's Name NMrr da Ts r e lgs Address #157; xi;e_Le ALe TQ , phone �- 1 <br /> Contractor l.� 400190" dress 282 f e r cense No.S Z2-6 Pho e1��7J' 7 Z <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION C1Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> -73 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES > -30 FST- DISPOSAL FLO.� PROP. LINEAW me`fiS <br /> FOUNDATION >15 AGRICULTURE WELL Lac— OTHER WELL_ PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / <br /> C7 Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavatio Dia. of Well Casin 2- <br /> I-G Domestic/Private ❑ Gravel Pack ? Tracy Type of Casing ��L Specifications '� <br /> I'I Public Other fl Delta Depth of Grout Seal C'tf Type of <br /> I I Irrigation L Approx. Depth I I Eastern Surface Seal Installed by S L>�-Uc,n / to <br /> Repair Work Done (J Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feat.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of sod to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Lina <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS ❑ <br /> 1 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 <br /> rules and regulations of the San Joaquin County <br /> Horne 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 <br /> employ any parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> 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- <br /> tion laws Ia." <br /> Thea nt mus wit for all aqui ad in t Complete drawing on reverse side. <br /> Sipped Title: ��( _. Oats: <br /> EIR DEPARTMENT USE ONLY r <br /> Application Accepted by Date '` Area Q <br /> PR or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stka, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CX CASH <br /> ff RECEIVED ey DATE 7�PERMIT''NO. <br /> EN 1}II IREV.sill 31 �/��t.It /�I DD51f <br /> EN 14-31 �/ LL [/c <br />