92-2291 - Laserfiche WebLink

Home Browse Search

c= SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRO MMENTAL HEALTH DIVISION e 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES R k-7 A (Complete inATrFPoi�cate)DATE ISSUID ,JU N •t 6 pplicatioa is here i 199® appllcation is madebin�e SBe Joaquin County for a permit to construct and/or instal the narENVIRONMENTAL �� '�� a��A� H Joaquin County public liance vith Sen Joaquin Count Health Services. Y Ordinance No. 549 and 1862 and lstlone r 1 3 r� the Rules and Regulations oP > Job Address .7 r City Lot Size/Acreage Owner's Name �u.; + Address! Q contractor iC.C�6A.�� Address � Phone.�,.� � TYPE Of WELL/PUMP; License No Z NEW WELL ❑ �. WELL REPLACEMENT License PUMP INSTALLATION ❑ DESTRUCTION ❑ Out of Service Well ❑ DISTANCE TO NEAREST; SEPTIC TANK .». SYSTEM REPAIR C] OTHER ❑ Monitors ---�: SEWER*LINES ng Well ❑ FOUNDATIONAGRICULTURE WELL--`�--- DISPOSAL FLO,_ PROP. LINE ---�� ;OTHER WELL`�� INTENDED USE -. _T,YPE:OF.W-ELL, PITS/SUMPS # n Industrial _ PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom Domestic/Private * t❑ Manteca Dia, of Well Excavation - =- — ❑ Gravel Pack € Dia. of We11 asin !•1 Public ❑ Tracy Type of Casing_ f g [:1 Other Delta Specifications 1 I Irrigation Depth of Grout Seal; ' Approx. Dept ! Eastern Surface Seal installed by Type of Grout l , Repair Work Done .rJ Type of Pump 1V� Well Destruction H.P. �I—----,_1 State Work Done _ r� �- ❑ Wel! Diameter Sealing Material & Depth' �+ Depth g Filler Material & Depth TYPE OF SEPTIC WORK; NEW fNSTALLATIONrt I REPAlRlADDITION f I DESTRUCTION I 1 INo septic systemer11111111 Installation will serve: Residence =---- available-within•200 feetlad'f public sewsr is _ Commercial— Other Number of living unite: `Number o befo of N Character of axil to a depth of 3 feet: {��f SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity--"— No. Compartments Method of Disposal Distance to nearest:I'l Well Foundation �. Property Line LEACHING LINE ❑ No. b Length of lines' !Total size FILTER FILTER BED n Distance to nearest: Well '-Foundation 1_-- Property Line SEEPAGE PITS - ' I f Depth i SUMPS t _ Size Number Cl Distance to nearest: Well Foundation s' DISPOSAL PONDS ❑ Property Liner I hereby certify that I have prepared this application rules and regulations and that the work will be done in accordance with San Joaquin county ordinances, state laws, and -of-the-San Joaquin-County Home owner or licensed agent's signature certifies the a following: -�- wo employ any person in such manner as to become subject to wok man's compensation tawsoof Calif ormance miahe Contractor hich this s hiring spermit is contra ed'. Isignashall tnot 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 California." The applicant at calf for all raga'ed inspections.I Complete drawing on reverse side. r' CJS Signed , w N Date: �- 0 DEPARTMENT USE ONLY Application Accepted by Date 2- j rea Additional Comments: Pit or Grout Inspection by i Date Final Inspection by Dat 2� , Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin,-p 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMtTTED CK INFO CASH RECEIVED BY 2DATE PERMIT`NO. 1 4 13-24(REV.s/x sl i [ 4 11.2E