92-3883 - Laserfiche WebLink

Home Browse Search

8 SAN JOAQUIN COUNTY AMLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STocgTON, CA 95201 K w�1P l 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 1862 and the Rules and Regulations of San Joaquin County Pubjlic Health Services. �1'�/^-// Job Address ` 7 5' City �-+ , `- Lot Size/Acreage Owner's Nam ` �ress µ'Vi`Q -- - -- -- Phone Contractor <C.S,=Address o- YO License NoPhone �Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT f7 DESTRUCTION o Out of Service Well ❑ PUMP INSTAL'LATIONX _ SYSTEM REPAIR El OTHER ❑ Monitoring Well ❑ 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 _ n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing `bomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public i, fa Other n Delta Depth of Grout Seat Type of Grout ~" I i Irrigation �� —.Approx. Da I I Eastern Surface Seal Installed by Repair Work Done Type of Pump ctl�` H.P. _ State Work Done 0. 1 Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIRIADDITION I 1 DESTRUCTION i I iNo septic system permitted if public sewer is available within 200 feet:l 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest:, Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest. Welt` � Foundation Property Line SEEPAGE PITS w f 11 Depth Size Number SUMPS LI 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 cenifies 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 cenifies the following: 1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of L'ia.The ap ant m �re"quired ctions. m lets drawing on rev rs side. i Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by r Date 2 Area 2 I I Pit or Grout Inspection by ..Date Final Inspection by - - Date i 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, CA 85201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 13-24 MEV.riasllS a -3$ EH 14.2E i