ARCHIVED REPORTS XR0008122 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT - 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 =IRE YEAR FROM DATE SPED- (Complete in Triplicate) Application is heretry 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 PublicGHealth Services. Job Address p - Cary TOCICTlJ,,) Lot Size/Acreage d��{s Nae � '` TiFs Ad res f//�'ll•I J E J" t � �G P a_ ,adr ,��7 3�s� ��v Contractor �/ 1 Z1i�rlss: icense No P e e TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT L I DESTRUCTION Q,0CM of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 7- 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation _ - Drs of Well Casing n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing &?r- T - Specifications r 1 PubBc n Other fl Delta Depth of Grout Seat S Type of Grout46",J`QfCi I i litigation —Approx Depth I I Eastern Surface Saul installed by Repair Work Done U Type of Pump HP State Work Done Well Destruction ❑ Wall Diameter Sealing material i Depth Depth Filler material i Depth ,TYPE OF SEPTIC WORK NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION i I INo septic system permitted if public sewer Ps available within 200 feet } Installation vwll serve Residence— Commercial T Other Number of Irving 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 LEACHING LINE Cl No 9 Length of lines Total length/size FILTER BED 0 Distance to nearest Well Foundation Property Line SEEPAGE PITS I i Depth Size Number SUMPS Ll Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ 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 rn the performance of the work for which this permit is issued I shell not employ any person in such manner as to become sublact to workman s compensation taws 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 Californla " The applicant must call for all required in�tions C e e r Prig on reverse side Srgr – Title `✓ Date FOR DEPARTMENT USE ONLY / � 29 L,- L7� tea' Date I& f L Area Application Accepted by _ - Pa of Grout Inspection by Date Final Inspection by Date �ddit*nal Comments Applicant – Return all copies to San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, GA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO INFO CASH 13-24 MEV „A As) 7,-) G C � � �n1 Ir Cry 7 C1-�� I �n ;�t�/