92-3236 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t ENVIRONMENTAL HEALTH DIVISION � I 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Publiq Health Services. Job Addresd City ( Lot Size/Acreage Owner's Name T i !J s Address o `A bl-e l-L Phone y Contractor_Ca/_C4-Ja-fP r' ,- s vis J License No. i 2o -11-Phone TYPE OF WELL/PUMP: NEW W ❑ WELL REPLACEMENT F1 DESTRUCTION. Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D 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 n industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack L-] Tracy Type of Casing_ Specifications Public 1-1 Other P Delta Depth of Grout Seal Type of Grout I i Irrigation _Approx. Depth 1 ) Eastern Surface Seal installed by Repair Work Done 'U/Type of Pump H,P. State Work Done Well Destruction Lys Well Diameter Sealing Material & Depth 07.3K, Depth Filler Materiel & Depth bP_ TYPE OF SEPTIC WORK: NEW INSTALLATION ! 1 REPAIR/ADDITION ( I DESTRUCTION l i INC septic sysie ermitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposai Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 ) Depth Size Number SUMPS LI Distance to nearest; Well Foundation Property Line DISPOSAL PONDS a 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 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 subcontracting 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 Calif The applica must call for requ' inspections. Comple a drawing on rev A side. Signed Title: /� � _ Date: �C F R DEPARTMENT USE ONLY Q Application Accepted by Date `� r Pit or Grout Inspection by Date Final Inspection by Dal •� �2L 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 IEEE AMOUNT DUE AMOUNT REMITTED CA NFO 4RECEIVED BY DATE PERMIT NO. 17 EH 13-21(REV.t/M 51 �1.[QUA /ri// /, ti4 � l! LiUCC��66,L/ C!