92-2250 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY -PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION 1 445 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 mads 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 ervices. Job Address City hot Size/Acreage S Address Phone r Owner's Name 7 Contractor Address I License No. z-1-LL Phone m TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Cl Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR /seg OTHER ❑ Monitoring 41e11 C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _,FOUNDATION_ --= AGRiCUL--TUBE WE ?I- L �- L. =-='ATHER-.WELL - _ ... -PITS/SUMPS.- ...... -r INTENDED USE TYPE OF WELL PROBLEM AREA C_ONSTRUCTtON SPECIFICATIONS ' Cl Industrial ❑ Open Bottom ❑ Manteca ' Dia. of Well Excavati6n'` Dia. of Wall Casing I C1 Domestic/Private C1 Gravel Pack7 11Tracy Type of Casing Specifications I ' 1'1 Public °Cl Other n Delta Depth of Grout SealType of Grout t 11 irrigation —,Approx. Depth I i Eastern ,F SurfacelSoul Installedfby Repair Work Done 0 Type of Pumptf H.P. - - State Work Done ' Weil Destruction E) Well Diameter Sealing Material & Depth j Depth f']�1 Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 leet.l Installation will serve: Residence-_ e- Commercial Other - r,"`=--- _ r Number of living uni#s: Number of bedrooms 'Character of soil to a depth of 3 fest: ` Water table depth SEPTIC,TANK. ❑„ Type/Mfg { Capacity No. Compartrnents * PKG. TREATMENT PLT.❑ �` tt r' Method of Disposal AY-- .Distance to nearest:• Well f Foundation Property Line i � t LEACHING LINE" Cl No. & Length of lines I Total length/"size FILTER BED ❑-,Distance to-nearest: _Welt..-- - Foundation Property Line''° SEEPAGE PITS 11-)'Depth, _ ! Size r Number y `- SUMPS LI, Distance to nearest- Well /_Founidatian Property Line -DISPOS-A-LPONDS'..': ❑ ; . _. �,��i a ,.�. ;- 1 .�'k-�. w--_ �---- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin countysordinances, state laws, and rules and regulations of the San Joaquin County r Home owner or licensed agent's signature certifies the following: "I'certity 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 I4w36f'California." Contractor's hiring or sub•contracting.signature certifies the follo ' g: "I certify that in the performance of the work for which this permits iasue4, l,shall employ persons subject to workman's compensa- i tion lava o al'or la." 1 f The:pplic��tclll for all requir d nspections. omplete drawing on reverse side , Signd X Title: J J Date: i. I r j 1 FOR DEPARTMENT USE ONLY S' •' / Application Accepted by Dated / �y Area Pit or Grout lnspsction by Date Final Inspection by"+_ Date Additional Comments: t ' 4 Applicant - Return all copies to: San Joaquin County Public Health Semites 1 EnvironmentallHealth Permit/Service's+ f 445 N San Joaquin, P O Box 2009,- Stkri, CA 95201 IFEE ''AMOUNT DUE AMOUNT REMITTED NFO CASH CK 0 RECEIVED BY �hl DATE PERMif''N'jO.+lEH t3.24IREV.iia51 /1 S 9 . � LD- QSpj EN 14,I11 } _ . 0