92-3311 - Laserfiche WebLink

Home Browse Search

} w SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ^ ENVIRONMENTAL HEALTH DIVISION SCANNED (� 445 N SAN JOAQUIN, PHONE (209)468-3420 [� /CePc_ �r. P 0 BOX 2009, STOCKTON, CA 95201 1 ...r}: PERMIT EXPIRES 1 YEAR FROM DATE ISSUED x� (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. Job Address __Zo `x'G- City Lot Size/Acreage Owner's Name �c // ! ` M' Address J O� r^� Phone Contractor % t fir• -Z0 .�—t�G -Address c�r� S Z/Z_ License Np32aj�0_Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR& OTHER O Monitoring Well (7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing XjDomestic/Private ❑ Gravel Pack O Tracy Type of Casing__ Specifications i'1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrioation _Approx. Depth __ �II VI Eastern Surface Seal Installed by Repair Work Done V Type of Pump H.P. State Work Done r1, Well Destruction ❑ Well Diameter Sealing Material & Depth V� Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ` r LEACHING LINE ❑ No. & Length of lines Total length/size yf`\ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 ornta. The appli ant must c for all requir ' pecti Complete drawing on re side. Signed X Title: —):�t S Date: ;��/9a OR DEPARTMENT USE ONLY Applic Ztl,nAcceptsd by A[Aap ' �, 0 St '__" Date Ar Pit or Grout Inspection by Date Final Inspection b Date, Additional Comments: 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 INFO AMOUNT DUE AMOUNT REMITTED CK I CASH R -EIVED BY DTE PERMIT'NOO (S . EH 12�IREV.�in sl U. EH Ia —1 �J