COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

APPLICATION SAN 4UIN COUNTY PUBLIC HEALTH .,_-iVICES 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 In 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. {� Lr Vvf--51 1L'} 1 t CSL 1 City , Lot Size/Acreage Job Address (� t I / Owner's Name t �Y1'1�CIeLl�1 SCl>✓IMI ,J �`ZrII�Address ` CO'Fr— i 1 U%k1 ,fir, 4K^F�Llo Phon191 �V41 —4'10() 6t52i10 4VGS�e�h Shra�a Explo , �, ,c 1�U 0,C,raVN LI TL C'5� (X1L)373-IM-, Contractor Address __ Icense No. Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER O Monitoring Well Dy 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 ' n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation the lam`5 Dia. of Well Casing n [l Domestic/Private O Gravel Pack A Tracy Type of Casing_ Specifications I'I Public N Other I-1 Delia Depth of Grout Seal i Type of Grout I I IniOation l CC Approx. Depth I I Eastern Sudaee Soul Installed by Vt'�S 1 f r 5t (Y:. E X`'10�•� tem V Repair Work Done U Type of Pump Nr H.P. .-__ State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth i Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted d public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial_ Other Number of living units: Number of bedrooms Charact Water table depth SEPTIC T Post-it'Fax Note 7671 Date 5'S'�15 Pages No. Compartments PKG. TRE To 1� From Method of Disposal Property Line S Co./Dept. Co. S�L� LEACHINI Phone# Phone yN a Les, 63 _ Total length/size FILTER BI Fax H Fax tt Property Line 11 Ifo' � SEEPAGE — Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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 peiiormance 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 applicant must call for ail required impactions. Complete drawing on reverse side. r Signed X 12C N t" L-tA6 /iUt,t/ti itle: I��-C C-� ��a 4\fi t:l� Date: Wa,(�1. FOR DEPARTMENT USE ONLY ,\ r Application Accepted by lv o Data � �� 11~ Area / Fit a Grout Inspection by 41_'4-,We date / t Final Inspection by G� r � Date t Additional Comments: �C'Ll tom► l 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 n(n^ FEE AMOUNT DUE AMOUNT REMITTED CK 111 RECEIVED By DATE PERMIT NO. �f INFO CASH Page age 1 3A EH 1724 Ii1EV,I/n 31