ARCHIVED REPORTS_XR0002204 - Laserfiche WebLink

Home Browse Search

1P131, ICATION ' SAN 10AQU I N c.DUNTY PURL I c_ HEALTH SERVICES I NV IRONMENTAI, HEALTH DIVISION 445 N SAN JOAQUIN , PHONE (209)468-3420 h 0 11OX 2009 , S rOC.K'I ON , CA 95201 PhRMIT EXPIRES i YEAR FROM DATE ISSULD (Complete In Trlpllcaie) ' Application is hereby made to San Joaquin County for a peritilt to r•on9truct. and/or install the work herein described This application is made in compliance with San Joaquin County Ordinance No 511v and 1862 and the RuleB and Regulations of San Joaquin County Public liealtth Service r � Job Address 2 41 0 GRAA/7- /�Z R 019 D C tv /��e_1� Lot 61ze/AL1 ea ( Owner aName-7DsT Address 2�419 /Us/� �PoAD Pf)one ~� -FT . � Ji✓4 /2 3�o s sARA%Gfi_Sk,✓,i/fr�,q/,�' ConLtactor6DYfCE Dh4WK rdd assrTLicense.NE'C D236R '�, Zi TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMFNT f] DESTRUCTION 0 Cut of Service Well 0 PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER C) Monitoring Well hY DISTANCE TO NEAREST SEPTIC TANK SEWER LINES _ _ DISPOSAL FLD N1A PROP LINE Y" FOUNDATION -d/14 AGRICULTURE WELL iN OTHER WELL=61A=PITS/SUMPS A64 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS // n Industrial ❑ Open Bottom 1_1 Manteca Dia of Well FxLavauon q Ora of Weil Casing -2- Domestic/ 2 ' Domestic/Private Gravel PackTracy Type of Casinq _ y Specifications ';cl -�� �.. f ) Public I 1 Other I t Delta Depth of Grout Seal Type of Grout-�Ar_ ' 1i Irrigation __ Approx Depth 1 1 Easiorn Suriace Seal Installed by �7(J✓� �� /�Qf��/iS/lT CC' „IA14 Repair Work Done (_7 Type of Pump _ 11 P State Work Done _ Well Destruction ❑ Well Diameter Sealing Material a Depth Depth Filler Material 6 Depth 1 TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRLICTION I I (No sepire system permitted if public sewer is available within 200 feet I Installation well serve Residence __ Commercial _ Other Number of living unite Number of bedrooms _ /_ Character of soil to a depth of 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 Ll No & Length of Imes _ Total longth/size I 1 FILTER BED r] Distance to nearest Weill Founaanon Property Lone y ' SEEPAGE PITS 11 Depth �_— Si:s - __ Number SUMPS i I 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 accoroance 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 follow rng I r-artify that in the p viforrnance of the work for which this permit is issued 1 shall not ' 8rRPI0Y any person in such manner as to become subject to workman s compansauon laws of California Contractors hiring or sub contracting signature certdles the following I certify that in rhe performance of the work for whiCh this permit n issued i shall employ persons subler_r to workman s compenlia tion laws of California The applicant must call for all requ rod inspections (ofripleto draniing on revorse side q Signed X. Tula l)1✓NEr? S /�GEni� _ Date ��2 3 — / A17✓A,dCF Sv�EC,y� .4/EX 4 /CA 5519-7 FOR DEPARTMENT USE ONLY ' Application Accepted by - __-_ ----_ --�- _ Date Area Pot or Grout inspection by gate Final Inspection by Date Additional Comments Appli,_ant - Return x11 copies to San 1oRgirin County Public 11 iiih aClvlc(.s Irivironmental IlPalth Permit/Servir�os 495 N San itytqu i ri P n Rnx 2009 5 Lkn, CA 95203 FEE AMOUNT DUE AMOUNT REMITS t D CK INFO CASiI RFCEIVFD BY DATE PERMIT NO H t�2�IREv ,iHsi --- - EH 1120 1