SU0009625 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HIM37R*i ENVIRONI(ENTAL HEALTH DIVISI 445 N SAN JOAQUIN, PHONE (209)46 _ P O BOX zoos, sTocNTOx, CA 95201 f, # PMWIT EXPIRES 1 YEAR FROM DATE ISSIIB<2 (Complete in Triplicate) V O L_ Application is hereby aide,to Ban Joaquin County for a permit to construct and/or install the work herein described. This application is Made in tajiliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Satmices. Job Address �;2 L �, n S ( AJT.Q V City Lot Size/Acreage Owner's Name 4// pjf', J A::1 Z), Address .2z �pr as�772 Phone i Contractor 414 JAddress icense Nq,22_15Z-4 a Phone TE OF WELL/PUMP: NEW WELL 11WELL REPLACEMENT Mal DESTRUCTION CT Out of Barviee ellLI TYPE PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE �J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,_: Industrial - Open Bolton 13 Manteca Dia. of Wall Excavation Dia. of Well Caving O i Domestic/Privets ❑ Gravel Pac*7 ❑ Tracy Type of Casing_ Specilicatiorts�- Cl Public ❑ Other fT Delta Depth of Grout Seal I I brtpat,on _Approx. Depth I I Eastern Surface Seal Installed by1. wl+Ay�D Repair Work Dori U Type of Pump M.P. Sub Work Done_ r , Well Destruction O WON Diameter Sealing Material a Depth v` Depth Tiller Material a Depth AN lfl&Q111NCOUNTY TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I 1 Ileo septic i ovaigbl�t (w, Installetion will serve: Residence_ Commercial_tf Oiher Dnme:Z;ne Number of living units: — Number of WdroOms n Character of spit to a depth of 3 fan: 4 6o sitQ CE Water table depth SEPTIC TANK O Typo/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE }K No, a Length of lines _. /�aQ- 1"_ Total length/size FILTER BED ❑ Distance to marest: Well Tsbf•Foundation Property Lina SEEPAGE PITS I 1 Depth Sim Number SUMPS LI Distance to nearest Wap Foundation Property Lina DISPOSAL PONDS O 1 hereby certify that 1 Mw 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 unifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not MMOV any parson in such manner as to become subject to workman's Compeneation laws of Cillfofnia." Contracloes hiring or sub-Contracting signature artiiies the following: "I comfy that in the performance of the work for which this permit is issued,I"I employ persons subject to workman's comport. tion taws of California." The applicant must calll ffm all sed inspections. Canplete Drawing on mesa fids. . Signed x G!•^-2� r��a Title: Date: FOR DEPARTMENT USE ONLY - Apolicsban Accepted by t Date Z TA,raa G•• I Pit Or Grout Inspection by Date Final Inspection by Dag e'N Additional Comments: - .I & SGP a&U&I,e d ass e b4c, Applicant - Return all copies to: San Joaquin County Public Health Services i ' Environmental Health Permit/Services 445 N San Joaquin, P O Box 2008, Stkn, CA 95201 FUFOEE AMOUNT DUUE�/\ AMOUNT REMITTEDK H RECENED Sl'. v/7 DATE�f��i1 PERMI/TT'N'O. . fn la141♦ir late.,..., f.l 41 IJV W /- / V fel