92-3470 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 i P 0 BOX 2009, STOCKTON, CA 95201 F i PERMIT EXPIRES L -YEAR FROM DATE ISSUED k (Complete in Triplicate) Application is hereby made to Sean 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. 3H S 7 , Cit .� Job Address y Lot Size/Acreage t I�. Address a 3 LA S °�] ��r r Phone Owner's Nam �(� pp ' r License No. ZZ� Phone �Q"S�aS Contract Address—sv CJ�5 TYPE Of" WELL/ LIMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service We71 L3 PUMP MsfALCATIGNZ SYSTEM REPAIR ❑ .k OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGR1CLfLTUFtE WELL OTHER 1/Vlt5UN1PS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation "° -f � Dia. of Well Casing ['I Domestic/Private ❑ Gravel Pack L1Tracy Type of•Gasing— Specifications I') Public El Other n Delta �Depth of Grout Seal � Type,of-Grout (` I I Irrigation _ _Approx. Depth I I Eastern Surface Seal Installed by 1� Repair Work Done U Type of Pump H.P. State Work Done — - Well Destruction ❑ Well Diameter Sealing Material & Depth ler Material & Depth Depth TYPE Of SEPTIC WORK; NEW INSTAL TION I I REPAIR DDITiON DESTRUCTION I k iNo septic system permitted if public sewer is available within 200 feet.). Installation will serve:. idents_ Commercial Other Number of living units-7 Number f W roo s Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg r• Capacity , " • No. Compartents�� PKG. TREATMENT PLT. ❑ 4 mMethod of Disposal Distance to nearest: Well - Foundation Property Line LEACHING LINE HCl 'No. 15 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE'R`ITS 5, M Depth _ SizeNumber u.., _ .,tSUe-..-�..� �* MPSj , LI bistance to nearest:�.�Well. iV/�a_ Foundation / Property Line .. ...,� :— �=•" —— ... ..�.- ,.} DISPOSAL PONDS ❑ r 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 M 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 mann4r as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature— certifies ignature—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 st call f I r uired inspections. Complete drawing on reverse side. 1 Signed X Title: t Date: M 1 0 i FOR DEPARTMENT USE ONLY Area /Application Accepted b- i Dated (Dit or Grout Inspection by Date inal 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 O Box 2009, Stkn, CA•95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT'NO. INFO1 07 ,L CASH / . EHi3Z4IREV.tixsr %(J; /1�//y� l! r� 06 EH 14•I4 i T !� C.+1