91-0763 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 i� P O BOX 2009,- STOCKTON, CA 95201 i PER�dIT 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 conVIiance with San Joaquin County Ordinance No. 54 an 1862 and the Rules and Regulations of San Joaquin County Public Health Ser,4ces. �1 Job Address 'Wo L! City Lot Size/Acreage Owner's NameLn�, _• Address L-7, L—Q+lPho4 —±J 30 l37 Contractor ddress MY) ense NoZ& Phone 1 �r,�P ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ ' PUMP INSTAL',LATION ❑ SYSTEM REPAIR 3 1 OTHER ❑ Monitoring Well L7 � 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack! ❑ Tracy Type of C n Specifications I'1 Public. !-1 Other ! Cl pelta depth �roouuf �V � J ;� N Type of Grout I jati _ Approx. Depth I 1 Eastern Surface Seal Installed by i Repair Work Done 0 Type of Pump H.P. State Work Done ZO��l es r Uan ❑ Well Diameter) Sealing Material 8 Depth ��j f lZE d Depth Filler Material b Depth _ �1Mt _ i, TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAiRlADDITION i I DE=STRUCTION l I (No Septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence T Commercial — Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: '''i Water table depth SEPTIC TANK " ❑ Type/Mfg F Ca stir r �I p Y 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 FILTER BED C7 Distance toj nearast. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS El Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS CII. - 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 signaturecertifies 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 applic st I f all re it in pections. Complete drawing on Iarse si .1� Signed Title: u Date:` OR PARTMENT USE ONLY Q Application Accepted by Date Area v Pit or Grout Inspection by Date Final I spection y Date Additional Comments: a Applicant - Return all cogies �to: San Joaqui County Public Health Services .' Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATEPERM7T'NO. + EH 13-241REV.rix51 EH 14.20"~..: Yom, mj'r f r v�Y - r