92-0424 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY PUBLIC HEALT4 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) Application is hereby made 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 Services. l- 3v L Gity Lot Size/Acreage /CJC� 0114 Job Address �� 4,, y Owner's Name -- Li .{r lkf MS Address �C'�Y.�� CLS PkoJ� Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION M Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C1 Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS nIndustrial C3 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Wel! Casing Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications Il Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I 1 Eastern Surface Sea! Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Se D FRJL Depth Fil 1§t t W TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR IA DITIO I DE5 RI TI o septic system permitted it public sewer is installation will serve: Residence s.:. Commercial— Other Permit may haVe X Ilhydd pWlftf 0 feet.) Number of living units: Number of bedrooms work being Completed or inspected t`^ Character of soil to a depth of 3 feet: J fJNt%J depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size Jan FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Site Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDSClI hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stat 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 sub-contracting signature certifies the following: "I comity that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The:ap sIt SII all requir ins ns. Co ete drawing on reverse side. ,,SS V Sign L~ Title: . o, - Dater FOR DEPARTMENT USE ONLY Application Accepted by - Date Area Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: Af 7S Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, GA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH K 9 RECEIVED BY DATE PERMIT'NO. INFO +�l)n a EH U•Y4 IgEv.1/N31 �.� .1 7 EH 71-20