92-2498 - Laserfiche WebLink

Home Browse Search

i; APPLICATION SAN JOAQUIN COUNTY*PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ' 1 445 N SAN JOAQUIN,PHONE (209)468-3420 P O BOX 2009, JSTOCKTON, CA 95201 ; PERMIT EgPIRES"14 EAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sam 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. x E! Job Address D & 11( ; S I'C�. -FGT0� Y� City Lot Size/Acreage Owner's Name _A Z-10a, f-;!J Address .144Ala Phone Phone i` Contractor Address (/��n/ 1�" ?/t�j_�cense No. Phone U TYPE OF WE LIPUMP: _ NEW WE WELL-REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Welh ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monit'orring Well DISTANCE TO NEAREST: SEPTIC TANK �5a SEWER LINES DISPOSAL FLD, ff2g PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL—� PITS/SUMPS— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO E> pQ C] Industrial pen Bottom ❑ Manteca" Dia. of Well Excavation pia. of Wei$ Casin = rl Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_. Specifications I'i Public is Other t n Delta Depth of Grout Seal Type of Grout i I Irrigation o;�Approx, Depth I I E#stern .,- Surface Seal Installed by Repair Work Done 0 Type of Pump H P. °* Tate WorkD ne_ Well Destruction -❑ Well Diameter Se Mater epth Filler erial & 1}epth. TYPE OF SEPTIC WORT: MEW INVALLATION l I' REPAI DOITION I I DESTRUCTION I hlNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Comms _""Other Number of living units: _ Number of drooms ' Character of soil to a depth of 3 feet: = r Water table depth - SEPTIC TANK ❑ Type/ g , Capacity y No. Compartments PKG, TREATMENT PLT. Cl Method of Disposal istance o;nearest: Well Foundation Property Line F ' . LEACHING LINE 4 ❑ No. & Le gth of lines Total length/size 'w FILTER BED ❑ Distance to nearest: Well Foundation Properly Line 4 I SEEPAGE PIT I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL ONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqup'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 uch manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-Contracting signature certifies the followin . "I certify that in the performance of the work for which this permit is issued, I shall.empioy persons subject to workman's compensa- tion laws of Calif o is. I The applicant ulr s on . Complete drawing on raver side Signed Title: _ Datg. ENT USE ONLY Application Accepted by _ Date I'. Area Pit or roe Inspection by Date = Final Inspection by Date Additional Comments L} �D ' •cam=�dc{ i r. i Applicant �- Return all copies to: San Joaquin Count Public Hert °th' Services t Environmental Health Permit/Services, + 445 N San Joaquin, P O Box 2009,1,Stkn, QA 95201 j r. a Rr FEE INFO FA50,C2VNT DUE AMOUNT NEMiTTED CASHRECEIVED 9Y DAT£ PERMIT'NO. EH13-24iREV.iixs)W� r CJ� rE7C7 �� i � � Z T �r A , ;� EH t1-Ze ! `