SU0006489 SSNL - Laserfiche WebLink

Home Browse Search

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) 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 Healt ervl (; y .sA XV r Job Address � CiryLot Size/Acreage y -32 Owner's Name Address Phone 7 C 7 � Contractor Address/ 5� License N Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REACEMENT F DESTRUCTION El Out of Service well ❑ PUMP INSTALLATION ❑ SYST%M REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL P OP. LINE FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA N RUCTION SPECIFICATION D Industrial ❑ Open Bottom ❑ MZ Dia. f Well Excavation Dia. of Well Casing C Domestic/Private ❑ Gravel PackTyp of Casing_ _-- Specdications rI'I Public 1.1 Other Dep h of Grout Seal Type of Grout ��I I Irrigation __Approx. DeSu ace Seal In led by j Repair Work Done ❑ Type of Pump . State Work Done_ �• Well Destruction ❑ Well Diameter Sealing Material a Depth Depth Filler Material L Depth ^ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is (} 1 available within 200 feet.) Installation will serve: Residence= Commercial Cheri / _ 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. ❑ Method of Div i'N� Distance to nearest: Well 04Foundation � Property Line _ LEACHING LINE ❑ No. 8 Length of lines of I length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire r �_,�, N/�y�j//mbar SUMPS LI Distance to nearest: Well Foundation x]11.Ak' 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 the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of California." The applica(9�)m�yEst call for 4required inspections. Complete drawing on reverse side. �( Signed 7_ Title: l.L�-�'h�t / Date: 2 t+_ f\ 1 A OR 7-7�`v��•a_r�ME�NT USE ONLY Application Accepted by 11.Cis,.., M - --'tea ��K'-+ Date rea Pit or Grout Inspection by Date Final Inspection by \ Date / JA7 K1.4 Additional Comments: C Applicant - Return III copies to: San Joaquin County Public Health Services +y/J✓ Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK HCEIVED BV DATE PER MIT'NO. NFO { p EH uax 1111N.v x e' P I C)C) EN r4.m