92-3423 - Laserfiche WebLink

Home Browse Search

a. APPLICATION 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 �r ,.(Complete. in Triplicate) I 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City_ - Lot Size/Acreage j?�a �0C_� Owner's Name. Address Phone p �s�kbC - 'Z 1�1\ �L cense No. �3C��] �l Phone v L Contractor Address — _ _ __ _ TYPE OF WELL/PUMP: NEW WELL ❑ WEt'-L REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS S_ INTENDED USE TYPE OF WELL PR4LEM AA_EA CONSTRUCTION SPECIFICATIONS \ CI Industrial ❑ Open Eottom� anteca Dia. of Well Excavation Dia. of Well Casing C.1 Domestic/Private ❑ Grave ick I Tracy Type of Casing_ Specifications I'3 Public 1:1.JJtfi r f� Delta Depth of Grout Seal Type of Grout ` I i Irrigation —..Appiox. epth' I ! Eastern Surface Seal Installed by Repair Work Done.b' Type of P` p / � HkP. State Work Done Well,Destruction © Well Deter !_3_ `eeelittg Material al 8 Depth Dep l ii1l4F^teri�1 & Depth T�YP OF'SEPTIC WORK: EW INSTALL':ATI REPAIRIADDITION l DESTRUCTION I I INo septic system permitted'il Oublic sewer is j �— available within 2W feet.) Installation,Wlkssrve Residence CommerciaE Other �b —A,Number of living units: ± 1 "/Number of bedrooms�Ql� �A"' i Character of soil to a depth of 3 feet. ' Water table depth SEPTIC TANK ML Type/Mfg Capacity1CaQC:7 No, Compartments QL PKG. TREATMENT PLT. ❑ r t Method of Disposal Distance to nearest: Well d5--- Foundation_ Property Line LJ LEACHING LINE i1 No. & Length of lines � C1.� �1D �, Total length/size � FILTER BED ❑ Distance to nearest: Welt wlC7S• Foundation - 2)0_— Property Line /12!2 � SEEPAGE PITS I I` Depth _ _ -Size �!Q%.Ql -NC4 umber. SUMPS Distance to nearest: Well Foundation, _ Property Line J=y 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 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 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 compensa- tion laws of California." The applicant must ci IV for all require ins ,tions. Complete drawing on reverse side. Signed Title: Qt.z P7 --- --- -- Date: /4�y-�'�9a . FOR DEPARTMENT USE ONLY 2� Application Accepted by Date '� Area �7 q Pit or Grout Inspection by Date Final Inspection by Osie J1LT. Z Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 F E AMOUNT DUE AMOUNT REMITTED tK RECEIVED 6Y DATE PERMIT NO. . EH 13-244REV.iixsii N EH 14 ot a ✓