92-3024 - Laserfiche WebLink

Home Browse Search

A SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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. Job Address �+�T'sf I /iI1 - e'voUCm City 57 Lot Size/Acreage j Owner's Name /J2�C 'ad Sd"" Address Ss �u �� Phone ` 10/ Contractor_J* u Address �� -I rise No45VW7_3 Phone a u /7 TYPE OF WELL/PUMP: i NEW WELL ❑ WELL REPLACEMENT C.1 DESTRUCTION ❑ Out of Service Well 0 PUMP.�INSTALLATiON [ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ^\ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications Il Public 1=1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation — Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump - VA H.P. __ ;2 State Work Done Well Destruction D WeffDifameter Sealing Material & Depth � Depth Filler Material 6 Depth 4 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I lNo septic system permitted if public sewer is available within 200 leet.l Installation will serve: Residence___... Commercial_ Other , Number of living units: I�Number of bedrooms I` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 111 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No."i Length of lines T -- Y Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line IM SEEPAGE-PITS 11 Depth Size Number SUMPS LIDistance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ If I hereby certify that I have prepares this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and h 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 manneri�as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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." 0 The applicant mu for all required inspecti s. Co to drawing on r se s �s Signed X a Title: ..,.. Date: R DEP TM ENT USE ONLY Application Accepted by Date -)4-9 ea Oft - Pit or Grout Inspection by �M Date Final Inspection by to Additional Comments: IN Applicant - Return all ,copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 13.24IREV.1ins[ QD'll EH 14.26 �� r �[