SR0003553 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQi]IN COUNTY PUBLIC HEALTH S VL�C^ 445 ENVIRONMENTAL AJUIN, HP ONE (209 468 4'90 P O BOX 2009, STOCKTON, CA 9520 C+ PERMIT EXPIUO 1 YEAR R [� (Complete in Triplicate) # __y.__1q Application is ttereby Wade to San Joaquin County for a permit to construct and/or install the work herein described. This application to W%Ae in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Futlic Health Services. Job Acldrasr 4tom� _ ,STATEN I31-RN_Ociry Lot Size/ncF �e E Owner's NaAddress- Address �;;:,,,,� Prim _77077i Contract Address License No. Phone TYPE Of WELLIPLIMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C1 Monitoring Well 1:3 DISTANCE TO NEAREST. SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION " AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Caring 1-1 Domestic/Private 0 Gravel Pack O Tracy Type of Casing_ Specifications I"1 Public M'vr^e fl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Instesled by Repair Work Oona LJ Type of Pump WiR. State Work Dons Well Destruction 0 WON Dia tar Sealing Material i Depth I sk"! Dept filler Material A Depth Wl=alAfe TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 14 DESTRUCTION t I INo septic system posmAtsd it public sower is available within 200 feet.) InstaNation will ram: Residence_ Commercial_ Other Number of Ming units: Number of bedrooms Charaetse of soll to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capa-,ity No, Comps PKG. TREATMENT PLT.0 Method of � s A in DietwwA to nearest: WON. Foundation Property LinaIR - ft 5 LEACHING LINE L1 No. b Length of lines Total length/vire FILTER BED 0 Distance to rteanat: Well Foundation _ Property Li^ 0 H SERVICES SEEPAGE PITS 11 Depth Size Number��u,,.641TAl Al 0111IN SUMPS LI Distance to nearest: Wall Foundation -- -- Property Lina DISPOSAL PONDS 0 A hereby certify that I haws prepared this application and that the work wits bs dons in accordance with San Joaquin county ardinancss, state Iaws, and 'Yonas and regulations of the San Jo@Aujn County Hpme owner or licensed aganVa signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1"not einploy any person in such manner ss to beCpne subject to workman's compensation taws of California."Contrector`s hiring or sub-contrsetft signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 19"1 employ persons subject to workman's compensa- tion laws forma." The a =nsl or ars +rigned in lions. Complete drawing reverse side. Sed Title: �'f TI— `�Yr� Data.,FOR DEPARTMENT USE ONLY en� 1 AppIkAnlon Adopted by Date _ Area Pit or Grout llv*wtion by Date 1 Final Inspection by ✓1 r 3 Oats Additions Comments- / y- an4j= adbJW#1QJgm 't _� - -- App 11eant Z�Ceturtt All co les to: Sae Joaquin County Public Health Services r^it�/y Environmental Health Permit/Services C) 445 N San Joaquin, P o Box 2008, Stka, CA 9520 tFEEp( �AMOUNT DUE AMOUNT REMITTED k H RECENED MY .017L. t:N 1N 17-,21 InEV,+��ni U V �Turn D v E4V V i