SU0011266 SSNL - Laserfiche WebLink

Home Browse Search

_ n APPLICATION t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 + P O BOX 2009, STOCKTON, CA 95201 a PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7 (Complete in Triplicate) l Application is hereby made to San Joaquin County for a permit to construct and/or install the vork 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. r 5127 f, / � Lot Size/Acreage 2 `��/ Cay Address f / EL. 11— �® i Owner's Name dress Phone Contractor s ense No. Phone TYPE OF WEL /P NEW WELL lot WELL REPLACEMENT Ll DESTRUCTION ❑ Out of Service well ❑ i t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ ^moi DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D(SPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications-I'1 Public 1-1Other (l Delta Depth of Grout Seal Type of Grout r 1 I I Irrigation _Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Staling Material k Depth �1 Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I `REPAIR/ADDITION I I DESTRUCTION I I [No septic system permitted if public sewer is —_-- Co i` available within 200 1"1.1l Installation will serve: R ideate_ Commercial Other� W q n RIv.�L ��i ��G'D�.• f. Numba�olJiving units; _Numbnr_of_bedrooms -.--- ----.---- Character of sod to a depth of 3 feet: Water table depth iSEPTIC TANK. ❑ Type/Mfg 4?�� Capacity I- No. Compartments [ 1, PKG. TREATMENT PLL ❑ Method of Disposal I iii 1 Distance to nearest: Well Foundation _ Property Line j LEACHING LINE ❑ No. g Length of lines- �qq Tonal length/size , 'I FILTER BED ❑ Distance to nearest: Well�j,L Foundationg9V Property Line d �+ SEEPAGE PITS I I Depth Size „L N mbar ` SUMPS LI Distance to male Wag - 10 Foundation Property Line DISPOSAL PONOS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and r �y 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 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 i compensa- tion laws of Californla." ' The applicant mu t Call for all re 'ed in pe do s. Complete dna en r/eJverse side. 1 AI rAV Signed rtle: (f. �� Date: FOR ARTMENT USE ONLY - (3 �l` 1 plidatlon Accepted by Date !3/� Area4- Z ?"1 �Pi Gnout Impaction by-if at Final Inspection by Tom//(�LDtna.7,e=&q 11 f� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services �i 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE{ NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED SY DATEn` N 11- ^PERM17N0. FEN 1344 IREV.l rxmi r0� rCl�..i '7 rJj< 17 ^[']' ' G (,� D 111JJJ 1 J