92-2609 - Laserfiche WebLink

Home Browse Search

APS,I CXT I ON SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 7P O BOX 200911, STOCXTON, CA 95201 Pe �- 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 1852 and the Rules and Regulations of San Joaquin County public Health Services. Job Address �0 Cc apq `C� City � � Lot Size/Acreage 6 Owner's Name Address s Phone Contractor.��4�(Led -�oWddress O� �Oese No.�Phone �l TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Xpomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_. Specifications III Public is Other Cl Delta Depth f Grout Seal Type of Grout ' I I Irrigation Approx. DepthI Eastern Sup a Seal installed by Repair Work Done :Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Seali Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I k iNo septic system permitted if public sewer is available within 2W feet.i Installation will serve: Residence_ Commercial`— Other r Number of living units: Number,of bedrooms Character of soil to a depth of 3 feet:_ -- - Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity T ' No. Compartments PKC. TREATMENT PLT.❑ Method of Disposal Distance_to nearest: Well Foundation I Property Line tiy,ylR 1M LEACHING LINE— CI No. & Length of lines TotalTlength/size Y Y FILTER BEd `' '` w CI- .Distance to nearest: Well - ,Foundation m Property Line SEEPAGE PITS _� l I Depih - Size Number '^ SUMPS C3 Distance-to nearest: .Well Foundation `Property Line DISPOSAL PONOS ❑ ""� I hereby certify that I have prepared this application and that the work1wilt 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's signature cenifies the following: "I certify that in the performance 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." Contractor's 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 mpensa- tion laws of California." The ap must II for all requir pection om a drawing;onreDer)iside. Signed Title: Date: -- DEPARTMENT USE ONLY Application Accepted by _ Y _"• A�1L�1 Date _ Z Area 0 Pit or Grout Inspection by Date Final Inspection by Date 3 F Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 009, Stkn, CA 95201 FEI INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY PATE PERMIT'NO. 4 + EH 13-24(REV. 5) l� } / EN 11•2E