92-2750 - Laserfiche WebLink

Home Browse Search

f i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (2,09)468--3420 P 0 BOX 20091 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 Sery ere. —rW/�0 fCS H-H•1n- Job AddressZZ.-3 a F City Q Lot Size/Acreage /QQ/- Owner's Nam+, P'?_ Address 291LE � +,P— PV Phone-_A3 G7�� �W �Contractar (�lwJ fV Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ID DEST, CTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ `... SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP AL FLO. PROP. LINE FOUNDATION f AGRICULTURE WELL _______-0 HER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONS7RUGT10N SPECIFICATIONS ` 171 Industrial ❑ Open Bottom ❑ Manteca Diak.of"Well Excavation Dia. of Well Casing \` (:1 Domestic/Private ❑ Gravel Pack Tracy` ypa of Casing_ Specifications I'I Poblic M Other n��Del__ Depth of G oouT3rrel Type of Grout SZ: I Irrigation .,_.._.Approx. Depth__4 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter i Sealing Material & Depth Depth I Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION FZUESTRUCTION I 1 iNo septic system permitted if public sewer is a! 1 available within 200 feet,) Installation will serve: Residence_ Commercial i Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. El Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ f. Method of Disposal Di anca.to eare%: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines X Total length/size I FILTER BED ❑ Distance to nearest: I Foundation Property Line SEEPAGE PITS 11 Depth f 5i Number SUMPS LI Distance to nearest: I Foundation Property Line DISPOSAL PONDS ❑ I 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 k 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 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." TJre applica must call for wired inspe.ctio omplete drawing on revere side. rgned Title Date: FOR E ARTMIENT USE ONLY Application Accepted byDate _t1 5 4 - Area Pit or Grout Inspection by € ate Final Inspecti y Date, Additional Comments: r " Applicant - Return all copies to: San Joaquin County Public Health Services { Environmental SanJol Health Permit/Services 445.N San Joaquin, P O Box 2009, Stkn, CA 95201 - FEEE;)' OUNT DUE EE7 AMOUNT REMITTED CASH CK RECEIVED BY DATE CPjERMIT'NO. EH 13.24[REV.i/n 5) INFO ��49 f IAV �iJ3 �j 'LH ! EH 14-2D