SR0081390_SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 445 NENVIRONMENTAL SAN O p Q HEALTH IN, PHONE (209)468-3420 AANNED P 0 BOX 2009, STOCKTON, CA 95201 PERMIT E%PIRES 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. Job Address � w City Lot Size/Acreage��© Owner's Name dressPhone "Zi�� Contractor sYe No. Phone Q TYPE OF WEL / NEW WELL WELL REPLACEMENT Cl DESTRUCTION Cl Out of Service Well ❑ 1 PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ _ 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 y F1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 1 I'1 Public I.1 Other Ul Delta Depth of Grout Seal Type of Grout 1 I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. _ State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK. NEW INSTALLATION IT REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is .� available within 200 feet.) Installation will serve: Residence_ Commercial= Other Number of living units: ---1---- Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity. No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well g 106 Foundation Property Line LEACHING LINE Cl No. & Length of lines `- 4Z A Total length/size / FILTER BED ❑ Distance to nearest: Well QQ Founaatron Property Line SEEPAGE PITS I I Depth Sire N mber ,ems SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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 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 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 following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for It re ed in pe, io s. Complete dra on reverse side. Signed Date: -..� FOR ARTMENT USE ONLY Application Accepted by ! Date -7-(3 C Area a N Pit r Grout Inspection by� ate - 2 Final Inspection by TT 54 22CZ-12=7 tib Date ,,//)2-� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 995 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK I CASH RECEIVED BY DATE PERMIT'NO. . EN t3-24(REv,r/H5) A ,� 6�j �7 f ter, �^ EH 14-20 - 1 V C tl�J `/ 'f j