92-3507 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-34REA- C E I V E . P 0 BOX 2009, STOCKTON, CA 95201DCT 0 9 1992 PERMIT EXPIRES 1 YEAR FROM DATE ISSUID DNMITA HEALTH (Complete in Triplicate) SRM Tr R L J e H�� Ld. This Application is hereby made to San Joaquin County-for a permit to construct and/or install he wor e n 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. l� ! City Lot Size/Acreage Job Address � � t �'�ddress �.i�r f)� ']1 � t I LQIV. �1�4��"Phone��`��`5 Owner's Name S Contractor Address UILicense No# �1� Phone OF WELL/PUMP: NEW WELL 0WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well 0 TYPE_(5F Monitoring Well OTHER PUMP INSTALLATION El SYSTEM REPAIR D E ,. DISTANCE TO NEAREST: SEPTIC TANK 2_LC_0�-- SEWER LINES 72'x/ DISPOSAL FLD- SLI - - PROP.SSUMPS FV` FOUNDATION �'� AGRICULTURE WELL 01k OTHER WELL INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS t� Cl industrial ❑ Open Bottom ❑ Manteca Dia. of Wekl Excavation Dia. of Well Casing Tracy Type of Casing- VOCs Specifications n Domestic/Private CI Gravel Pack Type of Grout i'I Public XOther fl Delta Depth of Grout Seal NA I I Irrigation —.Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work Done h Sealing Material & Depth Well Destruction Well Diameter - - Depth_ Filler Material & Depth ��A�CR �1' TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIRIADDITION i I DESTRUCTION I I INd sblerrnrsystithin m rented it public sewer is Installation will serve: Residence— Commercial^ Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK U 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 n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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'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 manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I comity that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." The applicant mu call_for all rokutrpd inspectI s. Complete drawing on r arse side. Title: Date: lqlqo Signe FOR DEPARTME1141VUSE ONLY 11P L?-v� Application Accepted by Date +5' Date !D Pit or Grout Inspection by Date ID- Final Inspection by _y._, q Additional Comments: pe5 c7 C -rt Ke C�oa ` ld [T). l 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 UK IFEE AMOUNT DUE AMOUNT REMITTEDLcA5H RECEIVED BY DATE PERMIT NO. INFO �^ 2 CJ[1�1�l1EH13-24(REV.II"w �� i "-� �� r £H 14.26