92-3805 - Laserfiche WebLink

Home Browse Search

APPLICAT1ON POA PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION i '��, —•. .. , 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 "�J PERMIT EXPIRES 1 YEAR FROM DATE S S,�iJ` n Z4 s yjZ (Complete in Triplicate) USI-IF47A� Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein dribedi';'•This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sera' Joaquin,County:,Pub1isIll, alth Sery ea. Job Addre City Lot Size/Acreage Owner's Name K3&1= Fdoq5 Address,2?469 $- X451" AQ„--D&Wo09- Contractor G4L&AZW D&4"&—Address S. kLZAZV No. i321 Phone TYPE OF WELL/PUMP: NEW WELL SZ, WELL REPLACEMENT 171 DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL= OTHER WELL:= PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Csfs'n� Ca Domestic/Privste� ravel Pack .Tracy Type of Casing-4725= _ Specifications I'1 Public a 1 Other fl Delta Depth of Grout Seat 90 1Z7— _ Type of GroutJ:*W%,q:: O IA-trrigation 490 prox, Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter sealing Material i Depth m Depth biller Notarial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I ) INo septic system permitted if public sewer is bj available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soli to a depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size I1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS CI Distance to nearest: Well Foundation Property Lina 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'ssignature 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 applicaftffts I r all Ked inspections. Cromplete drawing on r se side f SWC X C Date: FOR DEPARTMENT US LY Application Accepted by Data Area .6 �'A+ Pit or Grout Inspection by Dat Final Inspection by Date ` Additional Comments: It Applicant - Return all copies to: San Joaquin County PLic Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO QAMOUNT DUE AMOUNT REMITTED ASH/y7 SY DATE PERMIT NO. . EH 13-24(REV. EH Y4-26