92-2451 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j ENVIR HEALTH DIVISION ., A PHONE (209)468-3420 SAN j0AQU1N f"OUN''Y P @,`QD12009, STOCKTON, CA 95201 AZ - _J. •�- EI�N��-QNM�N'rAL HEr A&aRES 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 Servides. I� r,,,Job Address f City j Lot Size/Acreage L /7I � dress .�'�l� � I�_ Phone Owner's Name .5/—,,�Q,76 p v Contractor Address License No. _Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 n Industrial C3 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of WCasing C:1 Domestic I Private Cl Gravel Pack ❑ Tracy Type of Casing— FI i'1 Public Cl 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 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material a Depth Depth Filler Material 5 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 feet.l Installation will serve: Re idence Commercial — Other Number of living units: 17 Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK. Type/Mfg. CapacityJ2001 No. Compartments Z PKG. TREATMENT PLT.❑ , Method of Disposal Distance to nears I ell Foundation Property Line 9 1t01 C_ 4 LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS 11 Depth 1 Size �" " tNumber SUMPS 1}Q Distance to`nearest: Well i Foundation Property Line DISPOSAL PONDS ❑ I t� ! I PP 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 fotlowing: "f 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, I shall employ persons subject to workman's compensa r tion lows of California." The applicanust call for all required inspections. Complete drawing on reverse side. Signed Title: •� If. �• Date: Z IF FOR DEPARTMENT USE ONLY �Q Application Accepted by r Date 7" r� 9 2 t'Area_ 2 1 ��- Date Final Inspection by �- Date 2 -9-Lfit or Grout Inspection by _ Additional Comments: ' T•__, t Applicant - Return all copies to: San Joaquin County Public Health Services .r� Environmental Health Permit/Services 445 N San Joaquin, P O Box• 2009, Stkn, CA 95201 $ FEECKS AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT N0. Irl INFO f . EH 13.24[REV.I/A 51 A { EH 14.26 r