SU0000702 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 PAYMENT P 0 BOX 2009, STOCKTON, CA 95201 RECEIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR 2 6 1993 (Complete in Triplicate) SAN JOAQUIN COU,N/TY Application Is hereby made to San Joaquin County for a permit to construct anal/or inata�l�,P B�IFr1c�HEGAL H R�WWnrt ans application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 an bP 5 Joaquin County Public Health Se ces. l Job Address ' l /City Lot Size/Acreage Owner's Name Address l-� 1 `•— P l PR (� Phone Contractor Address License No. Phone _4(4_-yk_5,� TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ' PUMP INSTALLATION ❑ SYSTEM REPAIROTHER ❑ Monitoring Well ❑ 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 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Public Cl Other 1-1 Delta Depth of Grout Seal Type of Grout Irrigation Approx. Depth I I Eastern SYrfaee Seal Installed by Repair Work Done U Type of Pump sue) H.P. 11/7 State Work Done Well Destruction ❑ Well Diameter_ Sealing Materia'_ & Depth Depth ;Ln n �' Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ! I REPAIR/ADDITION i ! DESTRUCTION I 1 (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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O T /Mf YPe 9 Capacity No. Compartments � PKG. TREATMENT PLT. ❑ ; Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. 8 Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ! I Depth Size Number SUMPS LI 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pars i such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the in : "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 If Call is. The applic t call for all require spect�. o-plete drawing on r ers ide. Signed X Title: ��IDate: FOR PART EN S NLY o Application Accepted by Date ' /v Area / Pit or Grout Inspection by Date Final Inspection by a� f Date v Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE NFO AMOUNT DUE AMOUNT REMITTED KSH RECEIVED BY GATE PERMIT NO. • EH l3-N(R EV i i n S) - 0 ` � e `�� t� �4� ee- EH 71 26 J> 7" LJ �!J /J �/ y