92-3776 - 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 I (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 trade in compliance with San Joaquin County Ordinance No. 549 and 1862 end the Rules and Regulations of San Joaquin County Public Health Services. h q (�� Q r 33��1R69 Job Address t © u`' 4 City Lot Size/Acreage Owner's Name c ' `� L� �'"""`�'"' 'press'ra l(ts �• A1 �4___ � - Phone Contract 4 ' I Ietf Address VP Bol_,0 MACU License Noo..s-4Z VO Phone �'g�s d TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F) DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATIO_N,❑ SYSTEM REPAIR ❑ OTHER C7 Mon for ng.Well C7 1 i DISTANCE TO NEAREST: SEPTIC TANK`""`" 'SEWER LINES - 'tbISPOSAL FFLD. - PROP.. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .�. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Wall Excavation - Dia. of Well Casing fa Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'l Public [7 Other C1 Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seul Installed by �+V Repair Work Done U Type of Pump H.P. State Work Done - Well Destruction ❑ Weil Diameter' Sealing Material & Depth Y Depth + Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I iREPAI !ADDITION DESTRUCTION I I (No septic system permitted-if public sewer is available within 200 feet.i; Installation will serve: Residence— Commercial K Other Number of living units: Number of bedrooms , Character of soil to a depth of 3 feet: Water table depth j PSEPTIC TANK ❑ Typa/Mig I Capacity— No. Compartments KG. TREATMENT PLT. ❑ r Method of Disposal r Distance to nearest: Well Foundation Property Line t LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED [� Distance to nearest: Well "FoOndation Property-line --- � SEEPAGE PITS Depth S Size �� Number SUMPS a� 1 1 Distance to nearest: Well Foundation 0. Property Line DISPOSAL PONDS ❑ j 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 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 bicome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature i 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 t call for r u' inspections. Complete drawing on reverse si e Signed X Title: • - Date: s w t1=_-l_�C- FOR DEPARTMENT USE ONLY Application Accepted by Date F 23 97— Area Z t Pit or Grout Inspection by Date y ``. Final Inspection by Date Additional Comments: pt' Z i� v r/4 i r- - Applicant - Return all copies to: San Joaquin County Public Health Servic s i l Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AM VNT p E ` AM NT RE tTTEO+ C ECEIVED BY ATE PERMIT'NO. EM 17.21 IREV.tlxM ► �� Eli 11.2E - �T i