92-3489 - Laserfiche WebLink

Home Browse Search

.f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) quin County for a permit to construct and/or install the work herein described. This Application Is hereby made to San Jos application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules end Regulations of San Joaquin County Public Health Services. C Lot Size/Acreage r e/ Job Address City p� . Owner's Name 5 Address Phone Contractor ' ` 6�x'6e['o Address rpkf �-4'� j License NC). Phone TYPE OF WELL/PUMP: NEW WELL ❑ •WELL REPLACEMENT 17 DESTRUCTION D out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Manitari Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL CROP. LINE -� �- y- FOUNDAT16N AGRICULTURE WELL �. OTHER WELL PITS /SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing Ca Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing._ Specifications I"I Public C3 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth V Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION i I DESTRUCTION INailabptic systele thin m emitted if public sewer is Installation will serve: Residence— Commercial _ Other. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTERBED 1-1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number I IE` SUMPS Ll Distance to nearest_ Well foundation Property Line _ � ,�,,,.�,j - � -^ DISPOSAL PONDS D 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, an rules and regulations 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 permit is issued, I shall n employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of 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 mud call for all requ'ed Inspections• Complete drawing on reverse side. i'!/, Title: Signed X Date: FOR DEPARTMENT USE ONLY v Application Accepted by�~ Date 6 �2' Area � � r Pit or Grout Inspection by Biel Final Inspection by ._ Date/ Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO YZtk-d EH t3.241REV.1/K EH4-24