ARCHIVED REPORTS_XR0002202 - Laserfiche WebLink

Home Browse Search

APPLICATION v f)f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVISPS� ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O 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 549 and 1862 and the Rules and Regulations of San ' Joaquin County Public Health Services n Job Addles T 2 y 6,CAA// L R U/y City ��A C _ Lot Size/Acreage g4g el Ownar s Name- "` FARMS -7141C nAdd/rress 2 /'�1" le, �` � ��vPhone / 2 q Contractor 9D pF"r/✓ri,/� �y AddressAiP�4T�A �'f� �J4��i License too 7 Phone G v2 TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLID PROP LINE � i - - '---FOLINDATI(OW AGRICULTURE WELL _ OTHER WELL — PITS/SUMPS - ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom L7 Manteca Dia of Well Excavation �� Dia of Well Casing 2 Domestic/Private Gravel Pack (�Tracy Type of Casing_-Pi Specifications Sc� ' I 1 Public I I Other I-I Delta Depth of Grout Seal Type of Groutl✓1AT I I Irngallon Appfox Depth I 1 Eastern Surface Seal installed by Al)✓ AIrl !�)k r/11AJ/ Cry INL Repair Work Done U Type of Pump H P - --- State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth ' Depth Filler Material i Depth TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet I Installation will serve Residence — Commercial Other T N01 Number of living units Number of bedrooms _ Lb Character of sod to a depth o1 3 feet Water table depth ' SEPTIC TANK ❑ Type/Mfg Capacity No Compartments PKG TREATMENT PLT ❑ Method of Disposal Distance to nearest Well _ Foundation Property Line LEACHING LINE Cl No & Length of lines Total length/size FILTER I3ED n Distance to nearest Well Foundation Property Line ' SEEPAGE PITS 11 Depth Size Number SUMPS Lt 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 a signature certifies the following I certify that in the peiformance 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 Contractors 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 applicant must call for all required inspections Complete drawing on reverse side Signed .�------ Er 5 , ! v� �2 - 3 — ( 3 Title Date ApvA�JC� CJ,l F7T1/d ✓ AIE x A 1,-A S� 7/ FOR DEPARTMENT USE ONLY Application Accepted by I Date I Area Pit or Grout Inspection by Date Final Inspection by Date ' Additional Comments Applicant - Return all copies to San Joaquia County Public Ilealth Services Environmental Health Permit/Services � 1• 445 N San Joaquin, P O Box 2009, Stkn, GA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIt NO H1324IREv 1iw4Y H 14 26