92-2895 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 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 compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. e 1(09-K / Lot Size/Acres J Job Address � � +� City 8 Owner's Name 0,,L S Add*ress Phone 77-7 f1S Contractor Address E ` a ' License-No. Phone L- '� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLp.110� ��_� PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSYSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6 0 4 C7 Industrial pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing []omestic/Privare ❑ Gravel Pack 0 Tracy Type of Casing_ f Specifications Wr4 h. l'1 Public Cl Other n Delta Depth of Grout Seal ype of Grout �1 I i Irrigation ar1�Approx. Depth l I Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. ork Done Well Destruction ❑ Well Dia r Sealing lfateria h f� Filler Nfa erial 5 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.] Installation wiff serve: Residence— Commercial_ Other r Number of living units: Number of bedrooms �k Character of soil to a depth of 3 feet: Ater table depth SEPTIC TANK ❑ Type/Mfg Ca No. Compartments PKG. TREATMENT PLT. ❑ * Method of Disposal Distance to nearest: W811Foundation Property Line LEACHING LINE ❑ No. & Length of �. Well Torsi length/size FILTER BED 0 Distance to nears Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distan to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have pre red this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the n 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' or which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Califor ' The applicant m or all require omplete drawing on rev s' e. 00, Signed X Title: ______ Date: �OR DEPARTMENT USE ONLY lL Application Accepted by /�Date___ �lq'�!Z Area v ( 2— VimPit or rout spection by Date 2 Final Inspection by-, Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Bore 2009, Stkn, CA 95201 INFO FEE� AMOUNT DUE AMOUNT REMITTED CASH RECEiVEO BY DATE PERMIT NO. . EH r3.741REV.iiHsi W" 0"?. O0 4.2e EH 1LJ 1 4