92-2797 - Laserfiche WebLink

Home Browse Search

" $ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 I. P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I 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 made in compliance with n Jppquin County rdinance No. 5h9 and 1862 and the Rules and Regulations of San Joaquin county Public Health Services. • Q �[ City �` � - Lot Size/Acreage Job Address J , U� J Owner's Name Address Phone - - L.� IJI.J; ►1`t<icense too. 3 0s- Phone Contractor Address _. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ 4 . OTHER Q Monitoring Well - ....tPUMP--INSTALL•ATION.-❑�-.�--,-...«. -. PUMP .--�. -- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Manteca Dia. of Well Excavation Dia. of Well Casing ,.,,,-F. -.industrial —._„-❑_Open,Bottom._❑_.. __ C..l Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing_ Specifications - — I'I Public Cl Other 1-1 Delta Depth of Grout Seal Type of Grout I I Irrigation —,Approx. Depth i I Eastern Surface Sea! Installed by Repair Work Done 0 Type of Pump + H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth d Depth Filler Material & Depth 3 TYPE OF SEPTIC WORK: NEW INSTALLATION ! PAIRIADDITION I TRUCTION I I INo septic withm permfe 1itied if public sewer isavailahie O Installation will serve: Resince,` Commercial_ 9ther Number of living units: Number of Jledrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg I specify No. Compartments ' PKG. TREATMENT PLT. ❑ r � l Method of Disposal Distance to nearest: Well L Foundation f Property Line LEACHING LINE KL-.No. & Length of lines Toth! length/size rQQ# Property Line I .- FILTER BED CI Distance to nearest:,,,-_!Nell ' — Foundation - r SEEPAGE PITS I I Depth I Sire Number SUMPS 0 Distance to+nearest: Well 4 Foundation Property Line E DISPOSAL PONDS ❑ t f . 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 _� ,i" Home owner or licensed agent's signature certifies the-16110w1ng: "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 l certifies 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 r tion Ia sof fornix." The applicant m s for 11 re uir inspe, ons C rete d �-,.ng on r ae s'SignedT : Date: r r r FOR DEPARTMENT USE ONLY Application Accepted byre Date Area Pit or Grout Inspection by ++ Date Final Inspection , S E Additional Comments: tttt Applicant - Return all copies to: San Joaquin County Public Health Services F Environmental Health Permit/Services 445 N San Joaquin, P D Box 2009, Stkn, CA 95201 _FEE7 AMOUNT DUCE A OUNT REMITTED CK eAtW RECEIVED BY DATE PERMIT N0. INFO 11/w,��// . EH 13.241REV,1/n 51 sp- / / ` `•' !� �V /�l L/!-� O ( i G'- EH t1•2a