SU0011722 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION � o 40 SAN JOAQUIN COUNTY PUBLIC HEALTH OS `C" ENVIRONMENTAL HRALTB DIVISI 4R� �� BOX J2009INSTOCBTON(2CA)9 C u y� " P IT R 1 YE FROM D TE I » dOD �� ' (Complete in Triplicate) Application 1■ hereby mede,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 So. 549 and 1862 and the Rules and Regulations or San Joaquin County Public Health Serviceys..� r �} C ' Job Address ZZ 4 9 u' f'1'� I4M poed City L VIje Lot Sim/Acres.ge C'0 dC"5 ItL�7l�' kick, LfVIJ �e� 5sfr1e Phone $�-31� fDwner'o Namse�.t w..� ,t A�ddrepss��) yJ },2 1 r ' Contractor F't C ° A I'U1Mp - Address ,Lt l License No.�Phone 7 u✓� 1 W TYPE Of WELL/PUMP: NEW WELL WELL REPLACEMENT CT DESTRUCTION ❑ Out of Service Well ❑ + ' PUMP INSTALLATION . SYSTEM REPAIR ❑ OTHER b Monitoring Well ❑ 7., DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE Lar FOUNDATION AGRICULTURE WELLM OTRER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wall Excavation Dia, of Well Casing S r0omestic/Private Clill..Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 public' qt❑al aOther (l Delta Depth of Grout Seal I Q� I Type of Grout I I Irfigatiort 3 L Approx. Depth I I Eastern f I Surface Saul Installed by - Repair Work Done 0 Type of Pump 4r/14 _ H.P., 117 _ State Work Done Well Destruction O Well Diameter I C gosling MaDepth ��gyeCr I� ' Depth - 1°aael! ikpth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR d+6 STRUCTION 118No septic.system-permiiled of public sewer is 11 a C 4 qk available within 200 loot.)' i Installation will some."Reaitfatrce=�Gommercial-_,_O�� 1 °r. ��-v. � t'- � ' Number of living units: — Number of bedrooms V11 �i`FS""� Character of sos to a depth of 3 fast: aL1r+`� GTl"4L ,+, •dj$10N Water table depth SEPTIC TANK. ❑ Type/Mfg Q TAS apaeily No. Compartment PKG. TREATMENT PLT. ❑ E Method of Disposal Distance to nearest: Well Foundation Pt�ney Line r LEACHING LEVE ❑ NO. 8 Length of lines Total landt�sise V ' FILTER BED - ❑ Distance to nearest: Well Foundation Property Lind SEEPAGE PITS I I Depth Sire MUM ber, -: A.t SUMPS LI Distance to nearost: Well Foundation LNvit 6'1114 r�y ' DISPOSAL PONDS ❑ , E hereby trinity that I haus prepared this application.and that the work will be done in accordance with San Joaquin county ordinances, staie[am, and rules and regulations of the San Joaquin County Home owner or licensed agam'a iignature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall not ' employ any person in much manner as to blooms subject to workman's compensation laws of California." Contractor's hiring or sub•tontrecting signature unities the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman'a companies- don laws of Calif The opplic at trill for all rsqui ins tions. Complete dr ing on reverse sido. t ' Signed Title:OF - Data: OR DEPARTMENT USE ONLY J Application Accepted by Date Area—�-`Y �J Pito vows nepection by Data�S Final Inapeetion b Date Z Additional Comment: r 'ls�' Q�� =1{366^ 51784-ydiU,rts O Applicant - Return all sop+e to; Sar+aFJoaquio County Public H661'ta�Yervnc -+ -rAN• ,dam wpoo 3/q 3+F Environmental Health Permit/8 r i` '�13$� 15 T 445 N San Joaquin, P O Hex 2C-,,.,!-1---- `Z6111 rO v*r7F AMOUNT DUE AMOUNT REMITTED K CHVED av PERM fU 1 C14 _0