SU0004224 - Laserfiche WebLink

Home Browse Search

�.. APPLICATION SAN JOAQuiN COUNTY PUBLIC HEAL H%BEEF7 ' ENVIRONMENTAL HEALTH .DIVJl 445 N SAN JOAQUIN, PHONE (20 )�- P O BOX 2009, STOCKTON, C PERMIT EXPIRES 1 YEAR FROM D .(Complete in Tliplicat Application is hereby made to San. Joaquin County for a permit to construct and/or instj i the vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 5149 and 1$62 and .the Rules and Regulations of San Joaquin County Public Health ervices. \%w T1f1A(. +..,. O�dl_ re,y Qan tot Size/Acreage OtAk.0-4�e__ 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 in the performance of the work for which this permiEis issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 California.'' _ The applicant call fo l uiinspections. Complete drawing on reverse side. Signed Title: Date: j0d - _ FOR DEPARTMENT USE ONLY r Application Accepted by j~ + Date Area ` Pit or Grout -Inspection by Date Final Inspection by Data Additional Comments: C Applicant -'Return all copies to: San Joaquin Coun y Public Health;bervices :Environmental Health Permit/Services ' �^ �l 445 N San Joaquin x 2009, �,tkn, CA 95201 1 KI �1 r�.r•FEE Owner's Name .S • 11TAddress 1, 0 • '�`^""°r" s Phone RECEIVED BY U �tv� ` �L1 S Q Contract Address License N,'4ZZ_ Phone TYPE OF WELL/PUMP: NEW WELL 13WELL REPLACEMENT E1 DESTRUCTION ❑Out of Service Well. ❑ INFOUNT PUMP INSTALLATION ❑ SYSTEM -REPAIR ❑ OTHER OMonitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ;rD. PROP. LINE I. FOUNDATION AGRICULTURE WELL =AW04 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIOJ(f)UCfI1;A C7 Industrial O Open Bottom O Manteca Dia. of Weil Ex ava 10 Dia. of Weil Casing N JOA ❑ Domestic/ Private ❑Gravel Pack ❑Tracy Type of C s Specifications 11 Public f:l Other fl Delta Depih p � g.1r�jjf11ViS1OiVType of Grout I i Irrigation _ i — Approx. Depth I I Eastern Surface eeal Installed by Repair Work Dane ti IJ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR /ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other r - , Number of living units: Number of oms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK >< Type/Mfg ',Capacity 000 No. Compartments PKG. TREATMENT PLT. ❑ ,_ / Method of Disposal Distance -to nearest: Well /019 Foundation -- Property Line _ LEACHING LINE )K No. & Length of lines Total length/size X FILTER BED ' ❑ Distance to nearest: Well _�e)Q I Foundation _ Property lime SEEPAGE PITS Depth S Size Number ` SUMPS Well L1 Distance to nearest: WelFoundation _ f / Property Urw DISPOSAL PONDS _ - Cl 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 in the performance of the work for which this permiEis issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 California.'' _ The applicant call fo l uiinspections. Complete drawing on reverse side. Signed Title: Date: j0d - _ FOR DEPARTMENT USE ONLY r Application Accepted by j~ + Date Area ` Pit or Grout -Inspection by Date Final Inspection by Data Additional Comments: C Applicant -'Return all copies to: San Joaquin Coun y Public Health;bervices :Environmental Health Permit/Services ' �^ �l 445 N San Joaquin x 2009, �,tkn, CA 95201 1 KI �1 r�.r•FEE DUEAMOUNT REMITTED RECEIVED BY DATE P1EA7Mrr-No. INFOUNT .:9 13-24 (Rev. 11 e sl • / J 77EM t42a _..G