92-2394 - Laserfiche WebLink

Home Browse Search

f-I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES /Y�'•J_ /-'rF aC�/ �' ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46201420 A� P 0 BOX 2009, STOC%TON, CA Ii PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I e� (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 trade in compliance with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. d e�� 1L Joh Address City Lot Size/Acreage `�T*(J - c n f 1 7 I' Owner's Nam Address �� "� � ;Phone y r� ontract A re License Na. PboneCl 0 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well Ll Monitofing Well C7 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE'iWELL OTHER WELL. --y'""kITS/SUMPS • 1! P INTENDED USE TYPE OF WELL—xPROBLEM AREACaNSTRUCTION SPECIFIC�iTI NS` n Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excava .o .r Dia. of Well Casing �1 YA'Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications it Public CIOther n Delta- Depth of Grout Seal � Type of Gfou A rox. Depth I I Eastern Su c Seal Installed by 1 i I Irfl{} tion —.. pp Repair Work Done ❑ Type of Pump H.P.^ t _ 5t Work Dai Weil Destruction ❑ Well piame er Sealing Material & Depth - 3 Filler Material & Depth r f r TYPE. OF SEPTIC WORKi NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION i I (No,seplic system permitted if public sewer is available within 200 feet.). installation will serve: Residence— Commercial Other Number of living units: t Number of bedrooms I - Character of soil to a depth of 3last: Water table depth Sfp71C TANK ❑ Type/Mfg 5 C rty` t - No. Compartments PKG. TREATMENT PLT.❑ t Method of Disposal �a s. Distance to nearest: Well oundation h Property Line , 4 LEACHING LINE CI No. & Length of li Total length/size i FILTER BED n Distance to rest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number ! SUMPS Ll Distance to nearest: Well Foundation Property Line } DISPOSAL PONDS O I hereby certify that 1-have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules rind 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 note employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signat6re 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 applicant 6ujt call for all required ins ions. Comple drawing on reverse side. �5igned '°M. Title: �^ [ ' Date: JV ':?, 11 FOR DEPARTMENT USE ONLY , Application Accepted by \C� Date Area t Pit Gr Inspection b date � '� Fine). lnapection by Date J � j .Additional Comments: Applicant - Return all pies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 s FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO 3 z �r . EH 13-24 tREV.i/x51 EH t4'.28 71 ZJ e..