92-3665 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY PUBLIC- HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E (Complete in Triplicate) Application is hereby trade 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. Job Address lie City 0,,C Lot Size/Acreage n �j^ . l Owner's Name Address /t3o / AV-S Phone Contractor_ �j � �L -a Address A,4� License No Phone �y TYPE OF WELL/PUMP: NEW WELL 71 WELL REPLACEMENT n DESTRUCTION o out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l n1ndustrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Wall Casing (..I:Domestic/Private Gl Gravel Pack . ❑ Tracy,: Type of Casing_ Specifications i'l:Public la Other 171 Delta Depth-of Grout Seal Type of Grout ty - i I-Irrigation Approx. Depth I I Eastern Surface Seal installed by - �•} I H.P. Stats Work Done r„ Repair Work Done L1 Type of Pump Sealing welt Destruction ❑ Well Diameter Material.& A th r Depth Filler Material & Depth - ' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDi ON DESTRUCTION I I tNo s tic system permitted if public sewer is 4r i D�[7- �L,�f j Prjt- �C r &;3 within 200,feet) Installation will serve: Residence_ Commercial_ Other Numbir of living-units: J— Number of bedrooms Character of soil to a depth of 3 feet: 40 /3 W� ^R Water table 1 i SEPTIC TANK ❑ r T e/Mig N Capacity No.'Compartments �7 .'Method of Disposal j PKG. TREATMENT PLT. Cl � ''�'� - Distance to nearest:. �Well/�� .." Foundation —^ ��Property Line LEACHING LINE ( No. & Length of lines ✓ Torsi 1-460 FILTER BED n .;.Distance to.nearest:,_W..ell—_Foundation-l`�_ Property Line ii SEEPAGE PITS I I Depth Site Y/C3 3 Number '�- ti4`. _• A SUMPS Distance to nearest; Well Foundation 2J�'f" Pro`perty Line_Q! i DISPOSAL PONDS ❑ ; �" ' i t I hereby certify that I have prepared this application and that the work will tie 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 thefal[o+tiin8:'"i certify that in the perfor ance 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 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 must call for all required inspeelions. Complete drawing on reverse side. j Signed Xi'i(~i Tills: Otte FOR DEPARTMENT.USE ONLY Application Accepted by .Date �f Q Area Pit'or Grout Inspection by Date Final Inspection by Date Additional Comments: ` a Applicant - Return all copies to: San Joaquin County Public Health#Services ' Environmental Health_Permi,t/Services r .445 N San Joaquin,-P 0 Box 2009,YStkn, CA 95201 w ,--' FEE-�. MOUNT-DOES �AMOUNT REMITTED _C SH '4_"`RECEI]VED-9Y'"'"� °-DATE'"" 'PEAWT'N0. I - INFO f/Cf Cf- fK t1�e