1877 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC ERVICES ENVIRONMENTAL HEALTH D ru 445 N SAN JOAQUIN, PHONE ( -3420 3 P O BOX 2009, STOCKTON, PERMIT EXPIRES 1 YEAR FROM . (Complete in Triplcat i Application is hereby made to San Joaquin County for s permit to construct.and/or a work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and Vie Rules and Regulations f San Joaquin County ;�WX thw8�er�vicea. �� oj� Joh Address �/ Arx- City f Lot Size/Acreage Owner's NameA/w AddressA4 �DI�l.GI5►i [ Phonef D r B Contractor LGA O Address�&Q J916 JE9VQll�1W License Nom 4�M7 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f 7 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing * Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Il Public f..1 Other n Delta Depth of Grout Seal Type of Grout I i Irrigation ____ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material & Depth It TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION l I tNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Othe44ST 4*F.&d& �7 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0. Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line ii SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 laws, and h+ 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 o1 California." The applicant ust cal or all quire I ' ctions. Complete drawing on reverse side. ' rf:� Signed X ,, - Title: lgr�m& - Date: FOR DEPARTMENT USE ONLY Application Accepted by Btrn�� Date Area c Pit or Grout Inspection by , / Date final Inspection by Date T Additional Comments: `!' Applicant -.Return all copies to: San Joaquin Cou ublic Health Services 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 PERM17'N0. . EH 14.21(REV.r1Ksi R7 • F "� £H tt•26