SU0006844 SSNL - Laserfiche WebLink

Home Browse Search

r� APPLICATION "% -% -7 3 r— 35Y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 �� 7 P O BOX 2009, STOCKTON, CA 95201 C� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED !� Q p1 (Complete in Triplicate) . Application is hereby made 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 No. 54 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address =L�ti® -� P City Lot Size/Acreage ' Owner's Name Contractor TYPE OF WELLIPUMP: DISTANCE TO NEAREST: INTENDED USE 0Industrial ❑ n Domestic/ Private ❑ I1 Public I I Irrigation _ Repair Work Done ❑ Ty Well Destruction ❑ W Address 13 G[� kPli ,.. r Phone 3 Addresser ��\.rte �]� License No. ��— Phone.. NCV'V vvtu4 u WELL REPLACEMENT E] DESTRUCTION ❑ Out of Service Well ❑ MP INSTALLATION ❑ SYSTEM REPAIR ❑ . OTHER ❑ Monitoring Well ❑ PTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE UNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS nen Bottom ❑ Manteca Dia. of Well Excavation -ave) Pack ❑ Tracy Type of Casing_ her ❑ Datta Depth of Grout Seal Approx. Depth t I Eastern Surface Seal Installed by of Pump H. P. — State Work Done Diameter Sealing Material & Depth Depth Filler Materiel & Depth _ TYPE OF SEPTIC WORK: NEW INSTALLATION I>< REPAIR/ADDITION f I DESTRUCTION I i INo septic system permitted if public sewer is Ip - available within 200 feet.) Installation will serve: Residence iC Commercial _ Other Number of living units: _A Number of bedrooms 3` Character of soil to a depth "of 3 feet: Z.Q— C Water table depth SEPTIC TANK ❑v. Type/Mfg e_ Capacity PKG. TREATMENT PLT, Ll No. Compartments Method of Disposal Distance to nearest: Well - � Foundation 1 Property Line I Dia. of Well Casing Specifications Type of Grout LEACHING LINE ,No. & Length of lines Totai length/size l r FILTER BED n Distance to neares[: Well Z I f_Z Foundation 1 -�Property Line �C}` I SEEPAGE PITS Depth D, Size " Number SUMPS DISPOSAL PONDS 1 l Cl Distance to nearest: Well ate' FoundationL t3 r 2 r —--- Property Line � f 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 permit is issued, I shall not employ any person in such mariner 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 taws of California." I�' The applicant musVall for all re/9ui'radf inspections. Complete drawing on reverse side. Signed Application Accepted by Pit or Grout Inspection by Additional Comments: Applicant - Return all] XINFO FEE AMOUN Title: g--fLZ, Date: ZaS - 9-3 FOR DEPARTMENT USE ONLY Date Arae Date Final Inspection by copies to; San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, p O Box 2009, Stkn, CA 95201 DUE . EH 13-24 (REV. 1/96I7hj 1 114, ej0 EH 14-2e i tf AMOUNT. REMITTED C CX� CASH 1� �A417 RECEIVED BY DATE PERMIT'NO.