SU0006444 - Laserfiche WebLink

Home Browse Search

QCT y i�c APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 � &rp P O BOX 2009, STOCKTON, CA 95201 y at"A PERMIT EXPIRES 1 YEAR FROM DATE ISSUID ,� (Complete in .;- 'r�AUrPJI Application Is hereby made to San Joaquin County for a permit to construct and/or install the vorl(rherein This application is made in compliance with San Joaquin County Ordinance No. 5119 and 1862 and the Rules d'Hpgulhtionti.'of San Joaquin County Public Puublic He��a((lth Services. ,� �/J �JE./d W• �as-�i3L� City/ zWDy-0 Lot Size/Acreage' ✓ /1� � Job Address �� ,1 a„ "fy-)/��sVI/� Phone Owner's Name L/ �+- 4Z C, - . Address �y-i Contractor Address 2825E. Vrr-t License No. Z,Z.(.ag Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION V Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OT ER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK ti,tSEWER LINES 4J DISPOSAL FLO � �,�'c PROP. LINE _w / FOUNDATION —;-74---- AGRICULTURE WELL _ OTHER WELL�L PITS/SUMPS / INTENDED USE TYPE OF WELL PR BLEM AREA CONSTRUCTION SPECIFICATIONS y ❑ Industrial ❑pPon Bottom Manteca Dia. of Well Exc"on Dia. of Well Casing Ll Domestic/Private Gravel Pack ❑ Tracy Type of Casing_ r �� Specifications I'1 Public (-I Other (l Delta Depth of Grout Seal Type of Grou I I Irogabon _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ M Well Destruction ❑ Wall Diameter Sealing Material L Depth Depth Filler Material i Depth �e�— Z f4 ab TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I INo 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 wil 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 0 No. 6 Length of lines Total length/size 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 ❑ 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, an 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 oft m rnia." The applic`/nt\ u t call for ell re fired in pec ons. Complete drawing on r/efv�e/r/se side. Signed /�/Title: ✓ b Date: . Q L FOR DEPARTMENT USE ONLY / Application Accepted by Date `� Area Pit or Grout Inspection by - Data / Final Inspection by Date/a��9 2— Additional Comments: n Applicant - Return all copies to: San Joaquin County Public Health Services yt�sa Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO EH 11N IREV,Ir�sl EH 13 21 ///// ��✓✓ ESV' !(/ �i