92-2476 - Laserfiche WebLink

Home Browse Search

/ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 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 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 1w� City Lot Size/Acreage Owner's Name `/ +•e r�P f'i['r1 e S 0✓t Address � �� Za / Q h/A Y�P- - Phone 3 Contractor Address License No. Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 i 7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f.l Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing_ Specifications V1 Public is Other n Delta Depth of Grout Seal Type of Grout 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 ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTIO o septic system permitted if public sewer is available within 2W feel.l 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 SEPTIC TANK ❑ Type/Mfg Capacity-- No. Compartments PKG. TREATMENT PLT, D Method of Disposal Distance to nearest: Well Foundation Property tine ¢Jar�rr Wf'ryl iY t LEACHING LINE D No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line r SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well T 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 San Joaquin County Home owner or licensed agent's signature cenifies the following: "I comity that in the performance of the work for which this permit is issued, I shall not employ any person in such mariner 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all requir/ed,,i n sp ections. Complete drawing on reverse side. ,signed X � _{ , t��Kc+� j�l!'w Title: __ (9wil e- Date: v _EPARTMENT USE ONLY Q (� t B Application Accepted byADate A T Pit or Grout Inspection by Date Final Inspection by Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH K AT RECEIVED BY DATE PERMIT NO. . EH 13•N IREV.�ixsi 7 O0 7 EH 14-M ` / I7