SU0002389 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 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. City - 'Lot Size/Acre Address 1 '3 ubry kjr Ai ^ Q_= _ age I 1 C'•�11� Owner's Name ` � Q, r �RCV, �k ti Address L_S-, Phone C 12 Contractor LU>N Address 2!7:- p_ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION L1 Out of Service Well Cl PUMP INSTALLATION O SYSTEM REPAIR Cl 1 OTHER O Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES --- ISPOSjAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER(WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION PECIFI ATIONS CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well xe v tion Dis.,bf Well Casing f I Domestic/Private ❑ Gravel Pack II Tracy Type of C Specifications I'1 Public 11 Other (l Delta epth of out eal __ /"type of Grout I I Irrigation ___ Approx. Depth I I Eastern S (face sal Ins 11 y --_. Repair Work Done U Type of Pump _ _-_ H.P. _ __ St Work Dor _ Well Destruction O Well Diamet Sealipg tori Depth V" Depth Filler Mat X lal i Depth TYPE OF SEPTIC WORK: NEW IN TALLA ION REPAIR/ADDITION I DESTRUCTION I I IN septic system permitted it public sewer is i ailable within 200 feet.) Installation will serve: Residence Co ercial— Other Art') lU� Number of living units: Nu be,of be rooms _. Character of sollto a depth of 3 feet Water table depth \� SEPTIC TANK (1Z Type/Mfg \ _ Capacity C� No. Compartments \ PKG. TREATMENT PLT. El .i._ Method of Dispotat Distance to 'rest: Well 1�� Foundation Property Line Irl Z r � LEACHING LINENo. b Length of es _ �, Tot31 length/size U FILTER BED CI Distance to nearest: W f7 U Found l b Property Line SEEPAGE PITS 11 Dept Size _ Number SUMPS LI Distance to nearest: Well Fou dation Property Line_ —DISPOSAL PONDS ❑ ' I hereby certify that I have prepared this application and that the work wit be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Son 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 I 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 persons subject to workman's compensa- tion laws of California." The applican(Rsgst �� call fo�all re0if"inspeetions. Complete drawing on reverse side. / Signed X . 7J/. G i. - .. Title: Ll.;/y IF 10— Date: r DEPARTMENT USE ONLY L i Application Accepted by Date — J rea Pit or Grout Inspection by Date Final Inspection b 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CAK RECEIVED 8V DATE PERMIT NO. �j P4 13 24 01EV.r i n st C 7 u J / (`}Ir C� "1 -7 7 C (�� `�� EN ts.2e f