91-2820 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES , ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P 0 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 k 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. 4 Job Address 1T, ��. C;1_ +21 la City _ �"nG'fC�orl Lot Size/Acreage Owner's Name Address ��t'1 L✓ _ _ _— Phone i Contractor _ u fl e Address License Na. r �� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [-1 DESTRUCTION ❑ Out_of Service Well _.❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring We11H- DISTANCE TO NEAREST: SEPTIC TANK rF SEWER LINES— DISPOSAL FLD, PROP. LINE + FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM-AREA'" CONSTRUCTION SPECIFICATIONS { 111 Industrial ❑ Open Bottom ID Manteca Pia. of Well Excavation Dia. of Well Casing f ` n f.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public f-1 Other n Delta Depth of Grout Seal Type of Grout } I I Irrigation _.,Approx.�Del th rLYEastern a Surface Seal installed by Repair Work Done U- Type of(Pump H.P. State Work Done_ I" Well Destruction—0 _1Nell'p ameter Sealing Material & Depth r' Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I > REPAIR/ADDITION DESTRUCTION I i iNo septic system permitted if public sewer is available within 200 feel.I Installation will serve: Residence '� Commercial ,Other Number of living units: t Number of bedrooms j Character of soil to a depth of 3 feet: #4c&k,- Water table depth i SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. D S Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE IW-No. & Length of lines ' " 3tSt Total length/size o FILTER BED # 0 Distance to nearest: Weil C n Foundation - ! Property Line s i SEEPAGE PITS �^-' I I , Depth :_ Size -_ !S�_Y 16 L--Number i SUMPS w �Dista_nce to nearest: Well Foundation 4 __ Property Line DISPOSAL PONDS 0 z 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 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 all r aired inspections. Complete drawing on reverse side. 15 Signed K' — - _ Title: L� Date: 5 A I / ' FOR DEPARTMENT USE ONLY T Application Accepted by ¢ate Area Pit or Grout Inspection by Date Final lnsp ction bS..aS Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Servicesrr .� f�gr J Environmental Health Permit/Services Q 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFOFEE AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY GATE PERMIT'NO. ' EH 1 EH142piR['Y.tiNsl 11•� 1 "U4+� IC) �1 Yw