SU0005835 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION )p # SAN JOAQUIN COUNTY PUBLIC HEALTH' SE TES y.3 71 ENVIRONMENTAL HEALTH DIVISION 7 445 N SAN JOAQUIN, PHONE (209)468 P O BOX 2009, STOCKTON, CA 95m Qv PERMIT EXPIRES 1 YEAR FROM DATE MIA ��JJA ��V (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 Health SeN7, 10 . t. Job Address n 5 E3 ( � t CityLot Size/Acreage r�� Owner's Name ROO Vr kQfj J /t Address �+ V 1/��I�r� Phone -�31— Contractor WOb)—k SIC Address �"d wr �L� , License No. Phone q-31— TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION O Out of Service Well O PUMP INSTALLATION �Q QlQ.wSYSTEM REPAIR O OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U) Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ADomestic/Private O Gravel Pack O Tracy Type of Casing_ Specifications I'l Public Ll Other 1-1 Delta Depth of Grout Seal Type of Grout I I Irrigation __ Approx. De thS rface Seal Installed by Repair Work Done U Eastern Type of Pump H.P. State Work D e Well Destruction O Well Diameter ` Sealing Material & Depth Q tl Depth ry3/ Filler Material & 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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Weli Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS 11 Depth Size," Number SUMPS LI Distance to nearest: Wel! Foundation Property Line DISPOSAL PONDS O 4 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." icant mus call for al d i spections. omplete drawing on reverse side. Signed X LIM Date: FOR ART Application Accepted by Date Area ! Z?Zz Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services V Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK ll RECEIVED BY DATE PERMIT NO. INFO rtrt CASH (� . EH 13-24 IREV.r i n 5) �� I �v c-, 9-3—q-3 —3—G� 93-1919 EH a-ze ✓✓✓ 666J�� I 1 C)