SR0001823 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY ENVIRONMENTAL PHEALTH D VIUBLIC 1ID1W — TsS 445 N SAN JOAQUIN, PHONE (2 3420 1— P O BOX 2009, STOCKTON, N0111 PERMIT EXPIRES 1 YEAR FROM ACAJ him •.�� (Complete in Triplic AV it Application is hereby made to San Joaquin County for a permit to construct is application is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rulee and Regulations of San Joaquin County Public Health Services. Job Address i F t � City of Size/Acreage LW Owner's Named Address i� `0 _.�11 '� � tPhone oC n ri actofr r X t� 7 Address�� License No. �_ Lb_Phone 3, 4r ` TYPE OF WELL/PUMP: NEW WELL ❑ W L REPLACEMENT [71 DESTRUCTION ❑ Out of Service Nell 0 PUMP INSTALLATION IK �(��SYSTEM REPAIR D OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP_ LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia- of Well Casing ADomestic/Pfivate Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public Cl Other fl Delta Depth of Grour Seal Type of Grout I i Irrigation �w Approx. Dept I 1 Eastern Surface Seal Insrailed by I c' Repair Work Done C7 Type of Pump H:P. �_-_�� Sta[e rk Dona Well Destruction ❑ Well Diameter! Sealing Material & & th ( " Depth 9!51 Filler Material & Depth ° u TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR JAO DiTION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Otller Number of living units: Number of bedrooms {- Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. rk)mpartments PKG. TREPATMENT PLT. ❑ MorWod pf� lisposal Distance to nearest: Well . Foundation_ Property logo!_-... ` LEACHING LINE CI No. & Length of lines Total lengtla/sixe FILTER BED Cl Distance to nearest: Wall Founaation _ rop}rty,.Line', Q ^^i. ,i SEEPAGE PITS ( I Depth Sixa Numbm SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby comity 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 Joequin County Home owner or licensed agent's signriture cenifies the following: "I eanify 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 persona subject`to workman's compensa- tion laws of California," The applicant must tall for a!t reg!&ed ins tions- Com late drawing on r:j side. Signed Title: Data: _ FOR DEPARTMENT USE ONLY + Application Accepted by Date 2 Area Pit or Grout Irapeclion by Date Final Inspection by Da10 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services i Environmental Health Permit/Services RQ00I dZ i13 445 N San Joaquin, P O Box 2009, Stkn, CA 95 INFOAMOUNT DUEEAMOUNT REMITTED H RECEIVED 9Y DATE PERMIVNO- IREV.r x si