92-2745 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ETVIRONMENTAL ,HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209')468-3420 P O BOX 2009, STOCKTON, CA 95201 PEIWIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby nada to Sae Joaquin County for a permit to construct and/or inatall the vork herein described. This application Se made 1n eoapliaAce vith Sen Joaquin County Ordinance No: 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address • CityAi!T Lot Size/Acreage y - Owner's Name 4.fP!f rZ�ddress 05�1 A& 3 Phone onhactor Addtess License No. Phone TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION Cl Out of Service Nell. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well L] 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 1:l Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing_ SpeaiNcations. I'l Public El Other' . 171.Delta Depth of Grout Seal Type of Grout �, y�' � �1 I i i.ri{fation � Approx. Depth I I Eastern Surface Seat Installed by V J ; Repair Work bJ one LJ Type of Pump H.P. State Work Done„ Well Destruction ❑ Well Diameter Sealing Material 4 Depth _ J Depth_ Filler Material & Depth �. TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION E I DESTRUCTION I I (No septic system permitted if public sewer Is � Installation will serve: Residence— Commercial— Other available within 200 feet.) � n Number of living units: Number of bedrooms V Character of soil to r depth of 3 feels Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments . PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line S LEACHING LINE L1 No. & Length of lines To tat length/size FILTER BED n Distance to nearest: Well Foundation Property Line n - at SEEPAGE PITS 11 Depth Sire Number i. SUMPS Ll Distance to nearest: Well Foundation Property Line + DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and 7V 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, l shalt not ! employ any person in such manner as to become subject to workman's compensation laws of California,"Contractor's hiring yr sub-contracting signature certi}lea the fallowing: "I certify that in the performance of the work for which We permit is issued, I shall employ persons subject to workman's compenss- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed 7f , - Title: A Date: `, _ DEPARTMENT USE ONLY ' Application Accepted by *u. ... Ba Pit or Grout Inspection by Date Final Inspection b Date c �2_ _ Additional Comments: Applicant - Return all copiee to; Sin Joagditt County Public health Services t Environmental Health Permit/Services F 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DtIE AMOUNT REMITTED { IWO CASH RECEIVED 8Y DATE ry PERMIT 3NO. €h t/se / �`JJ / 3• :i