92-2873 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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) 3 Application is hereby made,to San Joaquin County for s 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. J ' Job Address /15oz t- - �if1 t ieE City ��'t. Lot Size/Acreage Owner's Name e, �_� 'r Address /15'02- e5eQfLd , __ /);,Phone r Address t . � nseNo*,3 Phone42_�9 ContraI t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN DESTRUCTION' Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK /2a(2-' SEWER LINES /2419'f DISPOSAL FLD. � PROP. LINE FOUNDATION AGRICULTURE WELL�2 OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CI Industrial ❑ Open Bottom ❑ Manteca Dia.'of Well Excavation Dia. of Well Casing ( Domestic/Private ravel Pack' I C1 Tracy Type of Casing_ C Specifications r I'i Public L1Other q� n Delta Depth of Grout Seal E� Type of rout } I I Irrigation p&�,Appro Oepth t I Eastern Surface Seui Installed by 1 Repair Work pone U Type of Pump H.P.- St4V Work Do @ Well Destruction 1�4 Well Diameter i-r Sealing Material rs Depth Depth Aff,016 q D Filler Material 8 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION ! I DESTRUCTION 'I I (No septic system permitted if public sewer is available within 200 feet.) installation will seive: Residence T Commercial Other Number of living units: .Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 1 �\ SEPTIC TANK D Type/Mfg Capacity' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line M LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS p - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, st71:shall and rules and regulations of the San Joaquin County Home owner or licensed agent's signature canifies the following:"I certify that in the performance of the work for which this permit is issuenot employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contractture 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 rust call for all requi inspections. Complete'drawing on reverse side. - Signed X / Title: __�rllreM Date: --!y 7— Z Application Accepted by FOR EPARTMENT USE ONLY Date V ~• Area t� Pit or Grout Inspection by ^^ Date d 7.d 2, Final Inspection by 1� DaleZ Additional Comments: d -j f 1/ f T A '^'�i 66 Applicant - Return all copies to: San Joaquin County Public eaith Services _A Environmental Health Permit/Services 445 N San Joaquin, P 0 Rox 2009, Stkn, CA 95201 iFEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. . EH 13-26(REV.tir<SI /� `1► a oa 36u' 2 Z / EH i47e � C/ G.P-`� 7'�l _0.Z%