92-2531 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY 'PU$LIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION R E C I V E D 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 ,J U L 0 6 1992 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERW ERVICES 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 Healltth Services. Job Address r1o7Y (I - � G2 L I& City��'P � &MtAcreage Owner's Name l r aM'P4_1 1A Addre s &2 Phone A 1'� 0__ 2Contractor�� ? & Lod Linse No. Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT DESTRUCTION O Out of Service Well O PUMP INSTALLATION SYSTEM REPAIR O OTHER O Monitoring Well 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 Cl Iu ial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 11 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. De th I Eastern lSurfaee Seal Installed by Repair Work Done U Type of Pump H.P. ` State Work Done , Well Destruction O Well Diameter Sealing Material & Depth t.J Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size V) FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O _—JIF I 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 sub-contracting signature certifies the following: "I certify 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 applican st call fr II r wired inspections. Complete drawing on rev se side. Signed X_ Title: d Date: F DEPARTMENT USE ONLY Application Accepted by �� Date 2'_ Area I Pit or Grout Inspection by Date Final Inspection by 2002S2Date Additional Comments: 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'N0. . EH 13.24IREV,iiR5) P�j 17—D EH 14.2E j/ G /d