CO0001390 - 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 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �J� `/A�// ��yy /� 7� Job Address 132-0 W GiVacg�'_ T[ t'� �5 KMA/ N City Lot Size/Acreage Owner's Named I 11 kl�.ddress Phone 774q- K--15F—A/JC�� nn VE [,( / �z{o-4 zp Contrac �A—DtorU 0iWJQ`brdress/U}D.-S70_C!"'L3:Z � License No. 61 1 1 0dPhone�J S�-'3 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT (-1 DESTRUCTION 1 Out of Service Well o PUMP INSTALLATION d SYSTEM REPAIR D OTHER O 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 [-I Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing f) Domestic/Private Cl Gravel Pack 11 Tracy Type of Casing---- Specifications 1'1 Public 11 Other 11 Delta Depth of Grout Seal Type of Grout I I IrriUation __ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump H.P. _ tate Work Done _ Well Destruction Well Diameter _ 11 Sealing Material i Depth ULd 1-0rdl 1z G//1/DS T q Depth � Filler Material L Depth ee lgm 4-1 EI6CAVA11VV TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted if public sewer is available within 200 feet.) 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED (_) Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS 1-1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 shall employ persons subject to workman's compensa- tion laws of California." The applica t ust call fo I required inspections. Complete drawing on reverse side. Signed X Title: Date: /fY Area FOR DEPARTMENT USE ONLY r� r II b ". Application Accepted by Date r Pit or Grout Inspection b ate final Inspectironbv Datr!✓ 3� Additional Comments: T � --- Applicant - Return all copies to: San Jo ui County Pu cal h Sery ces Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE PERMIT NO. EH13 24 IREV.r i n si D � EH 11-2e �../ `//J