92-2729 - Laserfiche WebLink

Home Browse Search

+ 4 _ S 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) 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 1.862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 41 / / A Y9•l7 City,/�kA'L4! Lot Size/Acreage RaQ0- AL. a4vE€see��' C� 1 Owner's Name T�2 .�C-WT &A29M Address 544-e Phone Contractor Address S-V C.IC t� !j�.'cS2dry"� License No.NOW �i Phone / TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n ` � DESTRUCTION 0 Out of Service Well L"1 {" Monitoring Well PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ~ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom 0 Manteca, Dia. of Well Excavation Dia. of Well Casing Domestic/Private Cl Gravel Pack El Tracy *' Type of Casing_. Specifications I') Public [.1 Other { Cl Delta Depth of Grout Seal Type of Grout r� I i Irrigation _ Apprax„Depth ' V Surface 5eai-Ins`[alled by 4 Repair Work Done 0 Type of Pump � H.P. k 2— &� State Work Don _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is O available within 200 feet.) j Installation will serve: Residence! Commercial Other Number of living units: Number of bedrooms j Character of soil to a depth of 3 feet: Water tab_lef depth SEPTIC TANK. ❑ Type/Mfg; Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines` Total length/size FILTER BED ❑ Distance to nearest:' Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number 1 SUMPS 0 Distance to nearest: Well Foundation Property Line x 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 f Home owner or licensed agent's signature certifies the following: "I certify that in the performanca 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 i 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 applican It call for all required inspecti s. Complete drawing on r arse ide. Signed X L. Title: Date: Z" -7 F DEPARTMENT USE ONLY Application Accepted by ADate Z— Area Pit or Grout Inspection by Date Final Inspection by Date ! 92 Additional Comments: I! 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 FEEINFO AMOUNT DUE h AMOUNT REMITTED /CASH 7 RECEIVED BY DATE PERMIT'NO, . EH 17-21 lR!V,rix 51 EH 11-20 Kf I y -