92-2480 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ` 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 x a PERMIT 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 conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ` !�77City M& Lot Size/Acreage Owner's Name b,r, ,fkIA Address. r/� - _ Phone ! i q i Contractor Address icense No. - Phone TYPE OF WELL/ UMP: NEW WELL ❑ WELL REPLACEMENT E7 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well ❑ 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing {„Domestic/Private G Gravel Pack ❑ Tracy Type of Casing_ Specifications 1'! Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I i Irrigation — Approx. Depth' I I Eastern Surface Seal Installed by Repair Work Done � Typo of Pump A."L_�_ _ H.P.'3 L State Work Don f Well Destruction ❑ Well Diameter O Seting Material & Depth Depth O Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.i 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ .. Method of Disposal Distance to nearest: Well Foundation Property Line NT PAYM LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line -SL.l�� SEEPAGE PITS 11 Depth Sire Number 5AN JCJAQ `' �lIC,E_ SUMPS 0 Distance to nearest Welt Foundation PropeftVFU ojv"Si0,\' DISPOSAL PONDS ❑ EI�VIR 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 sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I*hall employ persons subject to workman's compensa- tion laws of California." The applicant �must 'call for all required inspections. Complete drawing on reverse side. { n Signed Xf -1lDI.n� Title: Ratr� Date: v r-- FO EPA ENT U LY ✓ Application Accepted by Data Arame Pit or Grout Inspection by Date Final Inspection by Dal14 tt 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 FEE INFO AMOUN,.T DUE AMOUNT REMITTED CK# jr RECEIVED BY D TE PERM17'NO. • EN 13 24 EH 7426 /8 ��ff/