SU0009789 - Laserfiche WebLink

Home Browse Search

APPLICATION ��pp ��yy 3— 0 SAN JOAQUIN COUNTY PUBLIC HEALTH EHb6' An 00/0�� ENVIRONMENTAL HEALTH DIVISI Ryy 445 N SAN JOAQUIN, PHONE (209)4 %ta# P O BOX 2009, STOC%TON, CA 9 2PAC # PERMIT EXPIRES 1 YEAR FROM DATE laaUM (Complete in Triplicate) 11 �V/7 Application 1s hereby mede,to San Joaquin County for a permit to construct and/or Install the work herein descri ed"'this application is glade in conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. /�`-•1 p/ ^ Jbb Address v �z `� �"f� City ,6`" Lot Size/Acreage Owai a Name n�'`//p�J /Et e�� r� - f Mddress �iPG G TY Phone Contractor Address rt License No. Phone + TYPE OF WELL/PUMP- NEW WELL ❑ WELL REPLACEMENT (l DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well E.cavation Die. of Well Casing O Domestic/Pri ate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other .n Delta Depth of Grout Seal Typo of Grout 47 1 1 Irrigation _Appro._ Depth I 1 Eastern Surface Seal Installed by O Repair Work Done LI Type of Pump M.P. ___ State Work Done _ +J I Well Destruction ❑ Wall Diameter Sealing Material L Depth '` c/ Depth Filler Material 8 Depth dLAI TYPE OF SEPTIC WORN: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTR UCTIONi INOavailable septic system permitted it public sewer is available within 200 lest.) II Installation will serve. Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 toot: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments �- PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line Y LEACHING LINE ❑ No. B Length of lines Total length/size FILTER BED ❑ Distance to nearest, Well Foundation Property Line JJ SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to maresC Well Foundation Property Lim DISPOSAL PONDS ❑ -. 1 hereby comity 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 suGcomracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa tion laws of California." I The applicant must cap for all rre7equaed inspections. Compete drawing ons/reverse side. g ` Signed K,� � C`�7 �-rk Title: uz-7'ca-✓ Date: i 1/� j\�, Z s, �� FOR DEPARTMENT USE ONLY Application Accopted by ` ts� �U""7'7T�""�— Date y4'' Area Pit or Grout Inspection by - Date Final Inspection by ate' `---o'-�-% Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services + Environmental Health Permit/Services '945'N San Joaquin, P O Be. 2009, Stkn, CA 95201 -. ( ' FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED By DATE PERMIT'NO. i INFO CASH I^ S Ela i s.Z3 laEv.JJJ,,.,) EH 1324 ,,•J1 (g' '-7