SU0003868 SSNL - Laserfiche WebLink

Home Browse Search

i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 LP 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` (Complete in Triplicate) LApplication 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. ((�� LZ-3 � � ✓�% /�- I7 IL- U Cit Lot Size/Acreage Job Address Y Owner's Name %' ! /'76 r+-/.Vl Address Phone Contraclor 4,le ZL/G GLn Address R6 �%6 f',�J//�QL icense Phone Q� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I] DESTRUCTION EI out of Service Nell 0 LPUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS L INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications LPublic ❑ Other FT Delta Depth of Grout Seal Type of Grout I I Imgauon _Approx. Depth 11 Eastern Surface Senl Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material L Depth ._ CA LDepth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is available within 200.leeL1 G L Installation will servo: Residence Commercial_ Other 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 L PKG. TREATMENT PLT. ❑ _ _ Method of Disposal Distance to nearest: Well Foundation Property line LEACHING LINE No. L Length of lines l�j" Total length/size L it FILTER BED ❑ Distance to nearest: Well Foundation Property Line i L SEEPAGE PITS �v II Depth 1,9 /C-7- N Size In X %C7� _ umber SUMPS f` Distance to nearest: Well /vG Foundation L56 F7 PropertyLine •�r� DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and Lrules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "1 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 workmen's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman',compensa- tion taws of California." ` The applicant must call for all re ired ins p Loonns/./Complete drawing on reverse side. - ` Signed X / �"�" Title: . 6:GrG Date: `1 - FOR DEPARTMENT USE ONLY ` Application Accepted by ro,, Data 9Z- Area Pit or Grout Inspection by Date Final Inspection by Date tg 7 2 LAdditional Comments: Applicant - Return all copies to: San Joaquin County.Public Health Services Environmental Health Permit/Services L - 445 N San Joagyin, O Box 2009, Stkn, CA95201 rb FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY OATS PERMR'N0. INFO // , / / A 133r(REV.1rns15� /�4- � // `�'�� ✓ L4 lr.za