SU0005930 SSNL - Laserfiche WebLink

Home Browse Search

j SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Fi 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 Public Health Services. T Job Address City Lot Size/Acreage 4 Owner's Name,/�/i� �l, `t om dr ss CW Phone �� Contractor_ jAddress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 r 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 C1 industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing Specifications F ['1 Cl Public n Other Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done _ Well Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ff REPAIRlADDITION I 1 DESTRUCTION I I Mo septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence Commercial_ Other L Number of living units: ---�_ Number of bedrooms. — Character of soil to a depth of 3 feet: Water table depth �^ SEPTIC TANK. Q( Type/Mfg Capacity ®© tt.� No. Compartments Z ! f PKG. TREATMENT PLT, Q Method of Disposal -' Distance to nearest: Well Foundation Property Line } � LEACHING LINE 5( No. & Length of lines � © Total len g th/size +s FILTER BED CI Distance to nearest. Well Foundation Property Line _j SEEPAGE PITS 11 Depth _ /t� Size TC f'Z ?C 1 Number SUMPS 9 Distance to nearest: Well �� Fou dation Property Line DISPOSAL PONDS 0 IS0 r� 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 k 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 the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws 01 Califs Ia." The applicant f all required inspections. Complete drawing on reverse side. / Signed X Title: Date: 2�2 _ r� FOR DEPARTMENT USE ONLY !` �G b W Application Accepted by Date Area r! Pit or Grout Inspection by Date Final Inspection by Date Z- i iF - Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE OUNT REMITTED CK RECEIVED 9y DATE PERMIT'NO. INFO) EH 13-24{REV. L,EH 14.26