92-2051 - Laserfiche WebLink

Home Browse Search

. a Y APPLICATION SAN JOAQUIN COUNTY PI3BL I C HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISIONRECEIVED f n� 445 N SAN JOAQUIN, PHONE (209)468-3420� MAY 2 ! 1992 P O BOX 2009, STOCKTON,_ CA 95-2.0]. 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUi�PVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES 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 conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 00 S - Ci[ Lot Size/Acreage Owner's Name-119A ► --`y' � - - - Address 144 Phone Contrac3 �� Address 36 W 3QTLicense fVt Phone 1 r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION Cl Out of Service Well ❑ .PUMP INSTALLATION ❑ SYSTEM REPAIR &__L-� 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 1n I d i 1 O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications 1'i Public i.l Other (-I Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. � Depth I I Eastern Surfaee Seal Installed by pe Repair Work Done lw Tyof Pump H.P. State Work Dona Well Destruction ❑ Well Diameter Sealing Hateria.l & Depth 4 Depth Filler Material & Depth 1 TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIRIADDITION 1 I. DESTRUCTION I i {No septic system permitted if public sewer is Na i available within 200 feet.) O I Installation will serve: Residence T Commercial____ Other Number of living units: Number of bedrooms , Character of will to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity-------:-- No. Compartments `1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 -SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line ,o_R5POSAL PONDS. ❑. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, staie'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, I shall employ persons subject to workman's compensa- tion laws of California." /1 The applicant mus for ired inspecti hs. Complete drawing on v rse side. ' Signed Title: ZDEPARTMENT USE ONLY i Application Accepted by Date Z Area !!!R I Pit or Grout Inspection by Date. Final Inspection by Date�- Additional Comments: Applicant -- Return all copies to; San Joaquin County Public Health Services a Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE PERMIT NO. . fM1 3.24 tAEV.i i n sf ��ev EH t!•Ia