SU0006466 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby made to Sm 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Josb Address (' C`� L B yleT!.� City Ge 0 � A'N Lot Size/Acreage Owner's Name N2'SIt l l�sAt S0l•1 f hA. Address Phone O r kconlractor ws Az P 1r__. Address License No, Phone TYPE OF WELL/PUMP: NEW W" ❑ WELL REPL EMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ •' PUMP INSTALLATION SYST REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION GRICULTUR WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM EA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_� Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing_ Specifications ` I') Public Ll Other f1 Delta De of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I 1 Eas rn Surfac sul Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & epth Depth Filler Material & Depth I--- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) ` Installation will serve: Residence_ Commercial _ Other n Ii ICY Number of living units: _ Number of bedrooms _ Character of soil to a depth of 3 feet: _ �'A(,�sY1_&&11 Water table depth y SEPTIC TANK ❑ Type/Mfg nr1.L rl,"&t,- f _ Capacity Z'26 b 9 lifr No. Compartments PKG. TREATMENT P L,C7 I ldT�- Method off,Disposal Distance to nearest: Well 112cL. Foundation /CS Property Line aJS s� r,1 LEACHING LINE IP` No. & Length of ypas Total length/size / FILTER BED 17 Distance to nearest: Well.dam_ Foundation 16- Property Line �SD / SEEPAGE PITS [ I Depth 14' Size !2-A zin _ Number OZL SUMPS LI Distance to nearest: Well Foundation _A-0� Property Line DI SAL PONDS ❑ 1 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 manner as to become subject to workmen's compensation laws of California."Contractor's hiring or subcontracting 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." r_ The applicanntt,{{_^ust call forr all required inspections. Complete drawing on/�y�arae side. + eek( Signed K �.y-'LrL.s+,A R—AP A& Y Title: _L 1`�9-� Date: 1 � ) v - �� - - `Ap . OR EPARTMENT USE ONLY Application Accepted n Accepted by bw1c IVL Date ` ea d �` r.. Pit or Grout Inspection by Data Final Inspection b Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH R CEIVED BY ATE - PERMI7'NO. EH EH 1'2x IREV.iix 51 � wi I O (f C�-Z 211