92-2876 - Laserfiche WebLink

Home Browse Search

,V SAN JOAQUIN1COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BM 2009, STOCKTON, CA 95201 PERMIT EXPIIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ;I 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 g Joaquin County Public Health Services. Job Address City Lot Size/Acreage c; ca c— I� Owner's Name QLaa Address [ �/, /►/ �� 4 r AGLt_f ��hon Contractor !" Address I� License Na 7 q3 Phone TYPE OF WELL/PUMP: NEW WELL C3 �o WELL REPLACEMENT OESTRUCTIONX0ut of Sery ce Weil ❑ PUMP INSTALLATIONr 1. SYSTEM REPAIR C] OTHER ❑ Monitoring`Well G7 DISTANCE TO NEAREST: SEPTIC TANK aSEWER LINES DISPOSAL FLO. PROP. LINE( c! i r FOUNDATION AGRICULTURE WELL OTHER WELL46L.422_ PITS/SUMPS %.d INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i! C] Industrial Open Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing `Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications I'I Public „ C] Other Cl Delta " Depth of Grout Seal Zoo Type of Grout�Cm e✓L'r— I I Irrigation &�Qpprox. Depth ti Eastern Surface Seal Installed by --- Repair Work Done L7 Type of Pump _ H.P• r State Work one _ a Well Destruction Well Diameter Sealing Material & Depth ©NO tk V Depths ___ Filler Material,& Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIWADDITION I I DESTRUCTION I I JNo septic system permitted if public sewer is ~ I it available within 200 feet.) r Installation will serve: Residence— Commercial T Other f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT, 0 Method of Disposal Distance-to nearest:-- Wellll Foundation Property Line LEACHING LINE Cl No. & Length of lines IM Total length/size FILTER BED 0 Distance to nearest: Wslll Foundation Property Line SEEPAGE PITS I i Depth Size, �f Number SUMPS C! Distance to nearest: Well ,/Foundation Property Line DISPOSAL PONDS ❑ �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 �,- 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 taws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the petformince.of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." r. � The I V I applicant must call for all required i pections. CompletIa drawing on reverse side. dyL ,r, SigneQAOM Title: Date: QL )ENT USE ONLY Application Accepted byr Data L71 Z- Area Pit o G ou Inspection by Date , Final Inspection by �+ Date Additional Comments: I n Applicant - Return all copies to: San Joaquin County Public Health Services 6�� GQsffne{ — Environmental Health Permit/Servicesa 445 N San Joaquin BOlt 2009, Stkn, GA 852()1 '3Q Gant�Grr�L.- FEE / AMOUNT DUE AMOUNT RE ITTED I CK H RECEIVED BY DATE PERMIT p INFO / . EH 13-24 fREV-i i M 5) 2 �f /,1YL. H EH 14.26 LLG �J _/�^1 Hl Nt&& WD �� 9� .�rQ YT r �;