SU0005756 - Laserfiche WebLink

Home Browse Search

k APPLICATION s SAN O QUIN COUNTY PUBLIC HEALIE1 SM Gas ENVIRONMENTAL HEALTH DIVI 445 N SAN JOAQU IN, PHONE (209 P O BOX 2009, STOCKTON, CA %52.V a PERMIT EXPIRES 1 YEAR FROM DA E ED` �AI ! (Complete in Triplicat ) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork 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 Sery c a. r Job Address =� f y` w=�—� City di F LizfAcrPpy Owner's Name Fr�+h f✓ r 1 v' }1v�ddr s U (! L- 1 V . V k Q� if4 Phone � � I' `� �6 �,1�. Contractor M 111"1/YfC�.�] Address YID License No.lku� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-1 DESTRUCTION El Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 12 OTHER ❑ Monitoring Well ❑ I 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 0 Industrial ❑ Open Bottom L7 Manteca Dia. of"Well Excavation Dia. of Well Casing Domestic/Private., ❑ Gravel Pack El Tracy Type of Casing ; Specifications ' I 1 Public E1 Other {l Delta Depth of Grout Seat Type of Grout I I Irrigation _Approx. Dept I Eastern ip r urface Soul Installed by t Repair Work pone U Type of Pump H.. State Work,Done Well Destruction ❑ _ Well Diameter Sealing Material i Depth f ! t1l If, v Depth Filler Material i Depth TYPE OF SEPTIC WORK:-"'NEW iNSTALLATiON N1- REPA4R1A0OITI0N I I DESTRUCTION I I INo septic system permitted if public sevver is available within 200 feet.) lnstailitEion'willsarve: Residence_ ComrrSercial „ ,'Other Number.of living Oits: Number of bedrooms x Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. - ❑ Type/Mfg Capacity i No. Compartments PKG. TREATMENT PLT;❑ I Method of Disposal Distance to nearest: We11 � 'Foundation i Property Line” LEAFAING LINE El No. & Length of lines Total length/size FILTER BED C1 Distance to nearest: Well Foundation _ Property Line' SEEPAGE PITS i I Depth Size Number SUMPS CI Distance to nearest: Well ' Foundation Property Line' .DISPOSAL PONDS ❑ ; 11 heieby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and ruler:and regulations of the San Joaquin County ,Homo 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 workman's compensation laws of California."Contractor's hiring or sub-contracting signature .certifies the following: "I certify that in the potlormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion,laws of California." 4. ,The applicant must call for all required inspection . Complete drawing on reverse side. a Signed Date: FOR DEPARTMENT USE ONLY ;Application Accepted by RDate Ares At or Grout Inspection by to Final Inspection by Data a Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services Q'� NF 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 9-3g\.J !FE AMOUNT DUE AMOUNT.REMITTED �K 1 RECEIVED BY DATE PERMIT'NO. ASH wy. EH 13-24{REV.i�R sl EIS 14.20 ! v f