92-0953 - Laserfiche WebLink

Home Browse Search

i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--34120 tK P O 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 an� 1862 and the Rules and Regulations of San Joaquin County Public Health Services. n _ City jgl ►"s Lot Size/Acreage Job Address iIs � y � Owner's Name Jr� -_ Address Phone I. Address License No.;c2-- Contractor f'hone� f TYPE OF WELLIPUMP: �Ia NEW WELL ❑ •WELL REPLACEMENT n DESTRUCTION ❑ Out.of Service well El ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 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 Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing E7 Domestic/Private ❑ Gavel Pack ❑ Tracy Type of Casing._ Specifications I'l Public i-1 Other n Delta Depth of Grout Seal Type of Grout I I Ifrigation _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 6 Depth li -....-.....Filler-Material 3 Depth _�,.. r i-: •.--•;" Dept ` TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within'200 feetl� w; E Installation will serve: Rasidence/� Commercial."', Othar. r '� M. t Number of living units: I Number of bedroomsy Character of soil to a depth of 3 feat: Water table depth o+ SEPTIC TANK 0 Type/Mfg - �- Capacity N,Aompartments l PKG. TREATMENT PLT. D �_ Method`ot Disposal Distance to nearest: Well Foundatio Property Line r LEACHING LINE � No. & LenTotal lenth/sizegth of lines � � 9 FILTER BED n Distance,to nearest: Well -�(-V-wp_ Foundefion Property Line I SEEPAGE PITS I�1D� th%! Size Number p - SUMPS - CI Distance to nearest: Well Foundation —Propi^erty Line DISPOSAL PONDS ❑ II I hereby certify that I have prspared this application and that the work will be done in accordance with San Joaquin county ordinances, state Iaws, and rules and regulations of the San Joaquin County = 4 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 canify 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." a The applicant must call fora I quired inspections. Complete drawing o f Signed X � or Title: Date: -�M I ' I� OR EPARTIUENT USE ONLY r 4 Application Accepted by Date O r # Pit or Grout Inspection by II Date Final Inspection b Date�� Additional Comments: I� r i Applicant Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, 'CA 95201 i FEE AMOUNT pUE. --- :• -- ..,. m_gMOUNT REMITTED.-_ __CK -�:RECEIVED-$Y» -DATE PERMIT`NO. .INFO CAS.H'" { . EN 1374[REV.i i Kb) ....,k�- __. ..•�—•--_.—�..-a,.d•. .. - — - �T...-.»•.«..�y...�--�.�..•., � ��' �ALJ �.-� 3. EM 14.70 Sr ` 3 - 1 '