92-2374 - Laserfiche WebLink

Home Browse Search

APPL I CAlI ON POR PSM I T RECEIVED, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION J u N 2 3 1992 445 N SAN JOAQUIN, PHONE (209)468-3420 ENVIRONMENTAL HEALTH P 0 BOX 2009, STOCKTON, CA 95201 PERMIT/SERYIGE;� PERMIT EXPIRES 1 YEAR FRQM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in coupiiance with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Publi Health Services. Job Address I Z5 Z-7 Cit Lot Size/Acreage 5b6Owner's Name ) Address C1S Phone r eNZM 43 N.5 Y V Qir,,, S �es No. Phone f 2ZIv Mon ,actar TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 2 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED UBETYPE OF WELL PROBLEM AREA rCONSTRUCTION SPECIFICATIONS I-] industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ;-t omestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications I'I Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Dept Eastern Surface Seal Installed by 4A Repair Work Done U Type of Pump H.P. 2= State Work Done n �� Well Destruction © Well Diame r � Sealing Material & Depth S u Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADOITION i I DESTRUCTION I I INo septic system permitted if public sewer is �(1 —available within.200 eel.) Installation will serve: 'Residence— Commercial:_ Other .- Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments'. PKG. TREATMENT PLT.CI — � x = 1J*thod of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE �0 No. 6 Length of lines Total length/size FILTER BED0 Distance to nearest. Well Foundation Property Line F t SEEPAGE PITS l I Depth Size Number SUMPS ILI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ - „- �,l 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 i 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: 1 certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." r The appy nt r at call r iradj1poptions. Complete drawing on rev rse si Signed 1'4 q Title: Data: F R EPARTMENT USE ONLY Application Accepted by Date r `L Area Psi eP Pit or Grout Inspection by Date Final Inspection by -- Date ` 2 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CSA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'NO. INFO CASH . tEH,a-1411tEY.v/�s� 041 — f 5?2-- J EM N•Ie