SU0004580 SSCRPT - Laserfiche WebLink

Home Browse Search

APPLICATION -1,,r / Uu J" u SAN*'JDAQUIN COUNTY PUBLIC HEALTH`3lS ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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. 1 n a g Job Address cit 3 "A,,�j, r'f1• C'CY . �`71� -nLot Size/Acreage s Owner's Name�'A'Me_7dQu (\ � iS�Tp AdGdress ,=3S-q 3 fjS V`Nji� aw �1 Phone (7 Contractor J flTfr�L' s�0 V Address J O u c 44 'rvP S License No. � / 6 9& Phone 6 -33 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. —_PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fiA Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_` Specifications I'I Public 1-1Otherrl Delia Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth 11 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump $U H.P. -3 -- State Work Done_ S Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is O , available within 200 feet.) IN Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of will to a depth of 3 feet: Water table depth \\ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartm I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE ❑ No. g Length or lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line m SEEPAGE PITS 11 Depth Size Number /V SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 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 persona subject to workman's compensa- tion laws of California." The applicant Must call for 1 required iinspections omplete drawing on reverse side. Signed X �;�.>�72 ( _ Title: e, ,C Date• \(mow !\0) FOR DEPARTMENT USE ONLY �7 Application Accepted by `�� e- Data Z- At" 001A Pit or Grout Inspection by Date Final Inspection by Date 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 IF FDO AMOUNT OUE AMOUNT REMITTED CK RECEIVED BY �j DATE PERMIT'NO. . EH Ia-24(AEV.,rxs1 o EH 14-10