92-2595 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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) 6,0 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 300' ACL,6.t 1 a.t_n. R U i Infla_Y City 0 n Lot 91ze/Acreage Owner's Name Bank n4 .Sl a r,Ir i o n Address Phone i Contractor Address ?0,74 cg}n�License No.37a;r6_Ci�Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n OESTRUCTIOWL9 Out of Service Well Ll PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER 0 Monitoring well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications i'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I i Irrigation _ Approx. Depth I ) Eastern Surf Seat installed by N Repair Work pone ❑ Type of Pump H.P. State Work Done „ Well Destruction Well Diameter 6" Sealing Material & Depth 79444O Depth 9( •,_„•—_ Filler Material & Depth � fl�c1 -6 "30,44 •ti�rQ-rt--- TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION 1 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: 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: Welt Foundation Property Line LEACHING LINE Irl No. & Length of tines Total length/size RAR FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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 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 t 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 t ca f all r in ction Complete drawing on reverse side. Signed X Title: v% Xk Date: 22 92 F R DEPARTMENT USE ONLY Application Accepted by Date Xa—9 2, Area Pit or Grout inspection by Date Final Inspection b Date/ Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services f 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH `1 fH 1145IREV.i%-M'sarte- �•(� � i �.V�•o� silt Z � aIJ-�