92-2621 - Laserfiche WebLink

Home Browse Search

Id APPLICATION 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 I-IS0 ' E,"""'Z i / c City�w Lot Size/Acreage Owner's Name T'4�4_ % Address YJJ 74JJ ita225a d�,X I Phone "`"'l� Contractor AOSIL Address LI#LAW&A License No.x2s_! �Phoneu TYPE OF WELL/ M NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Oe 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public (:1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Stal lostalled by Repair Work Done 16 Type of Pump H.P. ,,( �* � State Work DoneZ' & Depth z Well Destruction ❑ Well Diameter IfSeali� Material � ,rQa? {�-i Depthr 44 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 T,2•14I f4AC Number of living units: Number of bedrooms— f/It Character of soil to a depth of 3 feet: Water � table pth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size PAYMENT FILTER BED ❑ Distance to nearest: Well Foundation Property ftcEnmD SEEPAGE PITS I I Depth Size Number 'j' 17 SUMPS LI Distance to nearest: Well Foundation Propacty ir? y�j ry DISPOSAL PONDS ❑ �r�lV,r�� + f S I hereby certify that I have prepared this application and that the work will be done in accordance 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 workmen'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 a required inspections. Complete drawing on reverse side. Signed X Title: L�f.�Ll-0-s.: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �Z res �� " Pit or Grout Inspection by Date Final Inspection by Date �— 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH13.21(NEV.+in 5) 'PAP �� P ��. EH 14.26 � 1 -77 ? "