92-0884 - Laserfiche WebLink

Home Browse Search

::.: �r•f•✓.c.J�rs ['k. moi,.,. ze�r.4 mss{-�.rr�c SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES • ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 • P 0 BOX 2009, STOCKTON, CA 95201 de PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ��. c • *4 Application is hereby wmde 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. r- •`� Job AddressO ` Lot Size/Acreage Owner's Na /'u Cr Address / 4 g- Phone r Contractor Address/ a License No. Phone TYPE Of WEL UMP: NEW WELL C7 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAI �❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION GRICULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A CO TRUCTlON SPECIFICATIONS 11 Industrial ❑ Open Bottom ❑ Manteca is. of Well Excavation Dia. of Well Casing (':1 Domestic/Private ❑ Gravel Pack L] Tracy T of Casing_ Specifications Fl Public 1:1 Other 11 Deli Depth Grout Seal Type of Grout I I Irrigation —Approx. Depth I astern Surface Se Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diamet Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I "REPAIR/ADDITION i I DESTRUCTION !No septic system permitted if public sewer is available within 200 feat.I Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth Q SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. CI Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. ✓9 Length of lines Total length/sire (� FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 Sen 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 such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fallowing: "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 ust c for I requiredjakpections. Complete drawing on reverse side. Signed X Title: C/ Date: Q ARTMENT USE ONLY Application Accepted bynftDate If Area CM _ Pit or Grout Inspection by Date Final Inspection by Date 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 AMOUNT DUE AMOUNT REMITTED I CASH K if RECEIVED BY INFO DATE AERMIT'NO. �q �/ /y�� . EH 13-21(REV.r/x31 Q [,7 7 7 - a 0 q 1 ,. EH 14-26 / //