SU0006521 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN oOAQUIN COUNTY PUBLIC HEALT 1` #CES ENVIRONMENTAL HEALTH DTVI i 445 N SAN JOAQUIN, PHONE (209 20 P 0 BOX 2009, STOCKTON, CA " '"'�" PERMIT EXPIRES .1 YEAR FROM DA E BE 66M (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or ineta the work herein described. This u 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. Job Addressf: City SteLot Size/Acreage 01 G.. 1` � Q � Owner's Name C ck M" Address Phone -1 � Contractor� _ N Address . 1C � � /`� License No. �7�f � Phone'a g' 7? TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION X<Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER a Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial `` O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fa Domestic/PTvate ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications i"1 Public _P Other f-1 Delta Depth of Grout Seal Type of Grout C I i Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump P. St to Work Done f �' �//'Seali Materiel & D t f✓ v�,,{j Well Destruction Well Diameter ng ep h �� a mA e n _ Depth Wov G Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIRJADOITION I } DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other ! Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth � i SEPTIC TANK. O Type/Mf 9 Capacity No. Compartments PKG. TREATMENT PLT.Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/siz iiXge FILTER BED Cl Distance to nearest: Well Foundation Proper p. SEEPAGE PITS , 11 Depth Size Number p _ SUMPS LI Distance to nearest: Well Foundationthe DISPOSAL PONDS ❑ RP� I hereby certify that I have prepared this application and that the work will be done in accordance wt ��il� a 6iouitiy' r'dinances, state laws, and rules and regulations of the San Joaquin county I Home owner or licensed agent's signature certifies the following: I certify that in the `'` '' performance of the work for which thQiperis issued, I shall not r. employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sui ontracting signature 1 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 Iowa of California." ¢� The applicant must call for allreq fired inspections. Complete drawing on reverse side. ' Signe A Title: e Date: a�l D�9y s FOR DEPARTMENT USE ONLY Application Accepted by II Date Area ,_, `. !I Pit or Grout Inspection by Date Final Inspection by Data j !rV1 �` Applicant - Return all copies to: Sa Joaquin County Public Health Services c�M 4 Environmental Health Permit/Services JJ h 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE �/T)i ` 1 +3 b INFO AMOUNT OUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NJO'.or . EW 17-20IREY.i/n51 r-V � EN 14-20 EL 23 ']