SU0002484 - Laserfiche WebLink

Home Browse Search

SAN JCX<UIN COUNTY PUBLIC HEALTH SE2WICES 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 eade.to Sm Joaquin bounty for a permit to construct and/or install the work herein described. This application is made in compliance with San 4caquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Courity Public Health Services. Qa-ftiA `dr, Lot Size/Acreage 46 g4;1a Job Address oiy BOwn9r s Name /�� 9D Address Phone /// ..(il C�y�//�� yyyy ' 7 ra � _ e s /r/`E� ice se No. /'W hone TYPE OF WELL/PUMP: NEW WE WELL REPLACEME D DESTRUCTION L) Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well LT 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 ❑ IrWustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 7'l stic/Private' ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Public 1-1 Other Ll Delta Depth of Grout Seal Type of Grout I I Imoation _Approx. Depth I I EafarnSurface Seal Installed by Repair Work Done 6)ugaeg J2 U Type of Pump H.P� State Work Dona r 117 Well Destruction O Well Diameter Sealing Material i Depth ` n Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR'/ADDITION I I DESTRUCTION I 1 INo septic system permitted it public sewer is available within 200 feet.) t. Installation will serve: Residence— Commerciial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth (`�1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments \` PKG. TREATMENT PIT. ❑ Method of Disposal , Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Properly Line - vc SEEPAGE PITS 11 Depth -Size Number „ SUMPS LI Distance to nearest: Well Foundation Property Line t� DISPOSAL PONDS ❑ I hereby cenify 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!V the San Joaquin Cotmty 7V• 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 compansa W ,on laws o CKrnh. �Ths apPlic or wired c pactions. Complete drawing on re aside. 71 Si rte � Title: Date: f`�) /l. FOR DEPARTMENT USE ONLY q �y + Application Accepted by U• C r^'� - tW4 Date ' �— 12' Area at. Pit or Grout Inspection by Date Final Inspection by -Dets� 8 93 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 AMOUNT DUE AMO NT REMITTED . CK RECEIVED BY D TE PERMIT'NO. INFO //A . EH 1124 IREV.1111 sl O —, 0-0 ,� 7�1 , /9 )y— L i EH 14.20 /� 1