SU0007192 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JuAQUIN COUNTY PUBLIC HEALTH SJ&AVICES ENVIRONMENTAL HEALTH DIVIS 445 N SAN JOAQUIN, PHONE (2 42 P O BOX 2009, STOCKTON, C A PERMIT EXPIRES 1 YEAR FROM D (Complete in Triplica of kC# 1� Application is hereby made;to San Joaquin County fore permit-to construct and orr the work herei application is made in co®pliancc with San Joaquin County Ordinance No. 549 an an Joaquin County Public Health Services. Job Address ` fd _ ZA7,C.J City"►' Lot Size/Ac ge d _ Owner's Name I Address G �j Phona r �7 ! • ',' ''7 c Phone Contract Address 63f-�' License No. sl_ TYPE OF WELL/PUMP: NEW WELL ❑ "WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 Y ; ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE 'u FOUNDATION AGRICULTURE WELL OTHER WELL PITSlSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pR F1 Industrial ❑ Ogen Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public 1-1 Other F1 Delta Depth of Grout Seal Type of Grout I'I Irrigation 'Approx. Depth I I Eastern Surface Seat Installed by R,y Repair Work Done 0 Type of Pump H.P. __— State Work Done adz"k g Wall Destruction ❑ Wel Diameter �A 1 Sealing Material Depth .914 i 1,c. �� ._ -� � �� " t Filler Material i Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial! Other Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: 1P1V ! SEPTIC TANK. ❑ Type/Mfg Capacity !17 PKG. TREATMENT PLT. ❑ � Distance to nearest: Wel Foundation Properm" N LEACHING LINE ❑ No. & Length of lines Total 1ARW_ I FILTER BED ❑ Distance to nearest: Well Foundation N IR"WWI HFAI ISION SEEPAGE PITS 11 Depth Size Number 5 i SUMPS Ll 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 eenifies 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 cenifi0s 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 ap scant mus all for al r it inspections. Complete drawing on verse side. 'Aa 4 Signed Title: Date: Ipplication FOR DEPARTMENT USE ONLY Accepted by Date Area Pit or Grout Inspection byData ! f /Final Inspection by Date d�� �? IJ✓��cE PRcCr�Jc.�[ l� J1J f l N �'f 4 �Q�' !/��Z C - ,- Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services �q `I I Environmental Health Permit/Services 1 I 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 "Z I FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. J rj 8 INFO + £M13.24 IREv.rir 5s J I EM 14-2a LD— I €i