91-2750 - Laserfiche WebLink

Home Browse Search

APPLICATION SPAN JOAQUIN COUNTY.PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION l i 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 E I 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 1$62 and the Rules avd Regulations of San Joaquin County Public Health Services. 385 Job Address � City Lot Size/Acreage \0a CILM 63-11,490Owner's Name Address Phone t Contractor Address License No. Phone TYPE OF'WEI'.L/PU NEW WELL C3 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well v DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ t INTENDED USE TYPE Of!�WELL PROBLEM AREA CONSTRUCTION SPECIFIC TIO S j/ C1�ndustriai i Open Bottom © Manteca Dia. of Well Excavat' n Dia. of Well Casing Domestic/Private i ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications r I'l Public ; - f-1 Other n Delta Depth of Grout Seal Type of Grout i I i Irrivation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done C7-N,,,�T_ype of Pump H.P. State Work Done _ Well Destruction ❑ Well-Diameter Sealing Material & Depth Depths ! Filler Meterial & Depth W TYPE OF SEPTIC-WORK: NEW INSTALLATION.I L.,..REPAIRlADDITION l I DESTRUCTION 'I I INo septic system permined if public sewer is' d: I. available within 200 feet.] ! installation will serve: Residence_116, Commercial— other _4L Number of living units: .t NumbeYEof bedrooms ` _ Character of soil:to.a depth of 3 feet' Water table depth : 9_ � - - - --- SEPTIC TANK Y f F ❑ Type/Mfg ' r r F i Capacity No. Compartments PKG. TREATMENT PLT, 0. t. i Method of Disposal } Distance o nearest: Well .FOndatioh Property Line f r a F 1 LEACHING LINE t 0 No!& Length of lines n Total length/size FILTER BED ❑ j stance 116 nearest: Well Foundation Property Line i SEEPAGE PITS j-'I I Depth'0'f Size Number SUMPS CI Distance to nearest: Well Foundation ___ Property Line DISPOSAL PONDS ; ❑ ` 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 laws of California." Contractor's hiring or sub-contracting signature certifies the following:;"I certify that in'thb peiformance of-the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California .. The applicant must call for all required'linspections. Complete drawing-on reverse side. Signed X E Title: Date: �.� — " FOR DEPARTMENT USE ONLY Application Accepted by v�""� Data y "'" �� Area Pit or Grout Inspection Date Final Inspection by Date Additional Comments: tJ�a.��+ L r +– Applicant r tieturn all copies to: San Joaqui County Public Health Services so s 7u--Ivf.c�w ' fxe } Environmental Health Permit/Services f7I 445 N San Joaquin, P 0 Box 2009, Stkn, GA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'N0. 0'. INFO t — ASH �j }/�� . EH 13-TI IfiEV,1�N51 LI`l - _ S�M 1��`+ 11 EH 11.26 "W1a