SU0005752 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIS;ES.- Z" ENVIRONMENTAL HEALTH DIVIS{'0� .. 445 N SAN JOAQUIN, PHONE (209)468-�P4#0__ __1_11- f� P O BOX 2009, STOCKTON, CA 95201 f PERMIT EXPIRES 1 YEAR FROM DATE �ISSUED. r ^ ► (Complete in Triplicate) ' f 1C/ Application In hereby made to San Joaquin County for a permit to cone tract and/or install thevnrJe-herein„�gacsbbed:'—"This application is made in compliance with San Joaquin County Ordinance No. 549 and 186 and the Ruies--lMrPegulatlons of San ► Joaquin Countybl %slt�9eis Service / City ae Job Address 1 //s //{ /'Y J it o/fS,ize/Acre a ^I, /r Owner's Name Address �ZI/ c _'� ' Phone Contractor ass License No. Phone ` TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION C1 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LI ESDISPOSAL FLD. PROP. LINE FOUNDATION AGRICUL R ELL OTHER WELL PITS/SUMPS _ `. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial [ Open Bottom .❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ GraveL.Pack ❑ Tracy Type of Casing_ Specifications �' I'I Public - 1:1 Other f1 D TX Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth ;,,14astern Surface Seal Installed by + Repair Work Done U Type of Pump H.P. State Work Dona _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth i Filler Material a Depth TYPE OF SEPTIC WORK; NEW INSTAL ION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) ► Installation will serve: Residence_ Commercial her Number of living units: _ Number of bedrooms Character of and to a depth of 3 feet: Water table depth ` SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ E )' Method_omits Dispgsp - Distance to nearest: Well O � oundation u lt Property Line Z I! Air tax LEACHING LINE ❑ No. b Length of lines 1 length/size FILTER BED ❑ Distance to nearest: Welt oundation " "Property Line t ► SEEPAGE PITS - .I I Depth Niumbe, SUMPS LI Distance to nearest: Well oundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will by 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 nc employ any person in such manner as to become subject to workmen's compensation laws of California." Contractors hiring or subcontracting signatur 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 compenru ► tion laws of California." The applicant at calwor 11 uired inspections. Complete drawing on reverse side. yU, Signed m1 Title: Date: sr FOR DEPARTMENT USE ONLY s^�AA V�Arn sSFr Application Accepted by Date p'rA 16«'Fk:&rs> RECELVE0 NM Pi r Grput Inspection by� Date Final Inspection by Ti��°/YJ nz 7—/5 ' Additi�iSal Comments: JIII. 1 8 1994 Applicant - Return all copies to: San Joaquin County Public Health Services SAN JOAQUIN COUNTY Environmental Health Permit/Services PUBLIC HEALTH SERVICES v 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 ENVIRONMENTAL HEALTH DIVISIC L IFEE NAMOUNT DUE AMOUNT REMITTED CK RECEIyED BY DATE PERMIT NO. 3 9 36� . EM O-241REV.veal fM 14 26