92-2747 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION L 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 San Joaquin County for a permit to construct and/or install the work herein described. This 1 application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules aad Regulations of San Joaquin County Public Health Services. ) Job AddressLtl City Lot Size/Acreage' IV Phone Owner's Name c Address M� Contractor Ae ha( jai AddressZ License No. Phone TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT ❑ DESTRUCTION m Out of Service Well 0 ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER/%, Moni ng Well �rL °�u� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL_ FLD. PROP.,LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [} Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'l Public Cl Other I fl Delta Depth of Grout Seal Type of Grout i I i Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. tate Work D ne _ �b a 1 Well Destruction ❑ Well Diameter Sealing Material & Depth 3 _ v� t Depth Filler Material & Depth `#Z tJytL 64— TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I Z Mo. septic system permitted if public sewer is ' available within 200 feet.) Installation will serve: Residence_ Commercial_ Other cklev� Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Sire Number ` SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t 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 Horne owner or licensed agent's signature cenifies 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 sub-contracting 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." The applica ust call required inspections. Complete drawing on reverse side. I Signed X Title: L1 r Date: IKOR DEPARTMENT USE ONLY p Application Accepted byCOG,, 1", " 1, Date 8� Z Area D Pit or Grout inspection by Data A Final Inspection byate �Z- Additional Comrnents: --S,Lt LA A Applicant - Return all copiesIto: San Joaquin County Public Health Services I Environmental Health Permit/Services 445 N San Joaquin, P O Bax 2009, Stkn, CA 95201 FEEw INFO AMOUNT DUE AMOUNT REMITTED CKS CASH RECEIVED fly DATE ) PERMIT'NO.9H 3 24 / `] EH t{•?atREV.i/M5V .�� i 1 Cr 2 Y /