92-0087 - Laserfiche WebLink

Home Browse Search

APPLICATION. S,�— -gSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES :!I ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 i PO—BOX 2009, STOCKTON, CA 95201 i 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:co4iliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Seg#es.466. / ,7/ rKff Job Address JCI-AEtrJ L.3• . Citya&'Cn ) Lot Size/Acreage' Owner's Name y4xo s T1L GH E Address K�hpne Ik IN 1110 f�LLf�'Cl D O Ll CG1, rzfq (Zf tO a T Contractor�(DLU_k_Ya�) Addres — License No, Phone iW"F WELL/PUMP: � -NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well PiUMP INSTALLATION ❑ _ SYSTEM REPAIR ❑ OTHER.❑ 14onitoring Well DISTANCE TO NEARES TIC TANK SEWER NES DISPOSAL.FLD. PROP. U LINE FOUNDA AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE I�TYPE OF WELL P AREA CONSTRUCTION SPECIFICATIONS if Industrial Cp open Bottom ❑ Manteca ia. of Well Excavation Dia. of WeII Casing M Domestic/Private- L� Gravel Pack ❑ Tracy Type o Specifications I I Public d l Other �` n Delta = Depth of Grout Sea Type of Grout I I Irrigation Approx. Depth: I I Eastern Surface Seal lnstaued by Pair Work Done 0 Type of Pump H.P. State Work Done_ it ell Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I-I DESTRUCTION I 1 (No septic systerri perrhitted if public sawai is available within 200 feet.) Installation will serve: Residence Commercial X Other �� $Atvp � psZfJ� Number of living units: !V/A Number of bedrooms L)1A Chiracter of soil to a depth of 3 feet: Water table depth A SEPTIC TANK: In i Type/Mfg 01p Capacity %LL No. Compartments ,2smo D%it „ PKG. TREATMENT PLT.X: C),,r GLE, 1 -31G1,647GD L.0 0 SYS.Metnod of Disposal Distance to nearests Well LO6y A Foundation t _ .Property Line LEACHING LINE , „ ❑;� No. A Length of lines Totit lengthtsize FILTER SED p it Distance to nearest: Well Foundation Property Line it SEEPAGE PITS I IDepth Size Number i SUMPS LI:I Distance to �tearest: 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 reguiations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this p Irmit is issued, I shall not employ any person in such manner as to become-subject to workmen'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 compensa- tion laws of alif,.ml.." I� The applica must call for uired in"ptions. Complete drawingAZRCT se side. i Signed Title: Date: �� Z FOR DEPARTMENT USE ONLY �p Application Accepted by Date i— 1 1~ Are!' Pit or Grout Inspection Data Final Inspection by I Data IM, Additional'Comments: 66 S fkVJ, // q� Applicant - Returni�Iall copies to: San Joaquin County Public Health Services rf�Jg i Environmental Health Permit/Services L( /`� 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 Y_/V Cyt � d IhI�FO® 4 AMOUNT DUE AMpUNT REMITTED CASH RECEIVED BY DATE PERMWND. • EH . 13-711REv.1i851 /y , p ; 7EH14.15 e0� f