92-2774 - Laserfiche WebLink

Home Browse Search

1/31 APPL•ICATTOST SAN JOAQUIN COUNTY PUBLIC HEALTH 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 fora 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. _ _ _"` 3/� i Job Address � + City ��Lot Size/Acreage r I , T ' 1, 0+ Address d © _ hone X200 Owner's Name M f' C S 7 • � �� S Gfc� CA— ,�D9.��GS—S71 Contractor S G O Addres g -icen5e IVo:S 4one TYPE OF WE NEW WELL ❑ WE L REPLACEMENT C] DESTR ION ❑ t of Service well. Cl " t Mor ire 4�s PUMP INSTALLATION O SYSTEM REPAIR C} ER DISTANCE TO NEAREST: SEPTIC TANK N!k - SEWER LINES � T DISPOSAL FLD. PROP. LINE Z� r FOUNDATION Ya';2S AGRICULTURE WELLAA OTHER WELL VAkA PITS/SUMPS �A ONS S _. be c,,,v �/ptx(td stir i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI C4 Industrial ❑ Open Bottom Manteca .- Dia. of Well Excavation &-l—Socificaboh pia. of Well Casing —1 Domestic/Private ( travel«Pack L7 Tracy Type of Casio" � �^ '�- Type of Groui�CC- 'i'1 Public i-1 Other (� Delta Depth of Grout Seal �'i I Irrigation 9's Approx. A_ E_�'a ,I stern iSurfaceSeal ln'stalled by e Repair Work Done LJ Type of Pump H,P, State Work Doe _ o + Sealing Material &--Depth t —7)67 s Wel Destruction ❑" WeflDiameteri OS{- 13 reAe2c�o.1,pA f Depth �" Filler Material & DepthTYPE OF SEPTIC WORK: NEW INSTALLATION ll REPAIRIAODiTION I ! DESTRUCTION tJI iNo septic system permitted if public sewer is available within 200 feat.) Installation will serve: Residence— Commerlal Other r ..,�. s Number of living units: Number of'bedrooms E !. Character.of soil to a depth of 3 feet: Water table depth ' i Capacity No. ompartments SEPTIC TANK O• !.Type/,Mfg, C PKG. TREATMENT PLT. ❑ - 51 Method of Disposal ' Distance to nearest: Well Foundation Property Line -. I LEACHING LINE r Ll No. & Length of lines ' —Total lengtlti/site" ' FILTER BEDS ❑ Distance to nearest: Well Foundation Property Lrne rRECEMD -4. { SEEPAGE PITS 11 Depth t Sire Number 1902 SUMPS Ll,_Dist_ance,to nearest: Well Foundation ! 'Pr perty,��In '' 7``l T DISPOSAL PONDS C1i SANIG I l I hereby certify that I have-prepared this application and that the work will be done in accordance wiHtRf�a��Qu �1�Pr�i+jtls�lte laws, and t rules and regulations;of the San Joaquin County r 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, I shall employ persons subject to workman's compensa- tion laws of California." " The applicant must call for all required inspections. Complete drawing on reverse side. e Signed- Title: Date: 7� �4� FOR DEPARTMENT USE ONLY f, t �3 Application Accepted by Date a II t Pit or Grout Inspection by Date incl Inspection by Data j Additional Comments: / t I Applicarit.-„Return,all copies to. ._San Joaquin County Public Health Services _ �Environmental'Heklth Perrriit/Services"`' 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO p, ! we57rl Z�` 72'Zn f EH 14•M