SU0001219 - Laserfiche WebLink

Home Browse Search

APPLICATION -" SAN jOAQUIN COUNTY PUBLIC HEALTH S RV II+IV IRONMENTAL ONE (209 46 31p0 445 N SAN XTOAQUIN, FAC � P O BOX 2009, STOCgTON, CA 95 O PERMIT MIRES L YEAR FROM DATE I (Complete in Tripl.ieate) uct and/or install the work he described. This construct tions of S t to Regulations a permit and A gu Application is hereby made,to S— Joaquin County for p application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules 4 Joaquin County Public Health j/+Services. /,/,/` �j� AAJJ� Lot Size/Acreage It X�'e 7� / Lr + /[�`1�L.7� ' `� ' City /� r` Job Address �j�jq d 7 Phone Address 73-53 y3 Owner's Namj-, License No. Phone i rr NEW WELL ❑Address out of Service Well. ❑ Contraclo WELL REPLACEMENT C1 DESTRUCTION Cl OTHER ❑ Monitoring Well U TYPE OF WELLIPUMP: SYSTEM REPAIR L]ST PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE V SEWER LINES ---- PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK �—CM "MAT AGRICULTURE WELL OTHER WELL 'a SPECIFICATIONS TYPE OF WELL PROBLE ^� ONS INTENDED USE vation Dia. of Well Casing r� ❑ Open Bortom 0 Manteca ia. of C} Industrial Type of Casing_ Specifications cY Grout I [:I DomesuclPrivate ❑ Gravel Pack Depth of Grout Seal w Cl Other (-1 Delta i I'1 Public Surface Seul installed by ��^^ I I Irrigation prox. Depth 13 Eastern r_ State Wof mv T of Pump _ H P' Repair Work Done YP6 Seating Material & Depth Wall Destruc C1 Well Diameter Filler !Material i Depth ;fl Depth I public stewer is DESTRUCTIO TYPE OF SEPTIC WORK: NTALLATION NEW INSI k REPAIRIADDITION lite (� Other s Installation will serve: Residence Commercial 3 ' Number of living units: Number of bedroo s Water table depth Character of soil to a depth of 3 feet: Cspacity� No. Compartments SEPTIC TANK. ❑ Type/Mfg Method of Dispo PKG. TREATMENT PLT. 0 :I o�ndation _ �--- Property Line�--- Distance to nearest: Well Total length/size LEACHING LINE No. & Length of lines Of Foundation �O� Property Line ,i FILTER BEDn Distance to nearest: Well � I Number I Depth Size SEEPAGE PITS f —�— Property Line SUMPS — ! Ll Distance to nearest: Well Foundation_ ❑ 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, an DISPOSAL PONDS rules and regulations of the San Joaquin County 1 Cenit that in the performance of the work for which this permit is issued, 1 shell not Home owner or licensed agent's signature certifies the following: " Y h employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or su wo(krta n's signature certifies the following: -1 certify that in the perfor ante of the work for wfiich this permit is issued, I shall employ persons subject to workman's compensa• tion la slitor tete drawing on reverse side. z Th applicant st cal I requir d ' c _ Date: Title: , Sig d FOR DEPARTMENT USE ONLY .. pate r �' ' Area n Application Accepted by Date ! I Final Inspection by p or-Grout Inspection by pate l Additional Comments: Applicant -• Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services ox 2009,ices GA 95201 445 N San Joaquin, P ` CK RECEIVED BY DATE PERMIT AIO. FEE AMOUNT DUE AMOUNT REMITTED INF . EM 13"24 ti1EV.1/%S1 - EN 14.26