92-3076 - Laserfiche WebLink

Home Browse Search

t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made t.0 San Joaquin County for a permit to construct and/or install the cork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. a120 /, y�t 1 Job Address C� C�tyJl Lot Size/Acreage 1 Owner'a Name f �IDJkVO Address ��- 16Phone ! r t sl�� ,�/ SR[J �d .�7�,�5/ Phone . J Contractor ~ L Addres r 0 License No, TYPE OF WELL/PUMP: NEW WELLS WELL REPLACEMENT DESTRUCTION ❑ Out of Service Nell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 124 r DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Ria. of Well Casing �Kpomestic/Private bQ Gravel Pack L1 Tracy Type of Casing_ 49 G �1 rSneVifir�ons I"I Public L-1 Other LJI Delta Depth of Grout Seat a r Pe of Grout I I Irrigation3nL Approx. Depth I I Eastern Surface Seal Installed by I Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material ra Depth _ Depth Filler Materiel 8 Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIAODtTION f L DESTRUCTION l I (No septic system permitted if public sewer is (� available within 200 feet.) 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 ❑ Type/Mfg Capacity No. Compartments t� PKG, TREATMENT PLT. ❑ Method of Disposal �^ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED L_] Distance to nearest. ,Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number t SUMPS 4 0 Distance to nearest: ; Well Foundation Property Line DISPOSAL PONDS-. . 0 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 o1 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 not 1 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature i4 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 compensg. ! tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. r ,0r� Signed x AM-92LIle �r _-- Title: --L 1u y, Date: !Yr31-1 FOR DEPARTMENT USE ONLY ►1 +� Application Accepted by Date ! f Area Pit o�Inspection byVJ0 Ila-a Date 9 1Z- Final Inspection by Ilate Additional Comments: Applica R rn all copies to: San Joaquin County Public Health Services , [ ff Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 ill! FEE INFO AMOOUN/T�/DUE AMOO.UUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. . AO Er+ 13-11(REV.1)K5J01-,8f li�V / / 96� 9a�3a 6 { EH 71-20