SU0009228 - Laserfiche WebLink

Home Browse Search

APPLICATION 3 / SAN JOAQUIN COUNTY PUBLIC HEAL'JgI(,'�SERY ES ENVIRONMENTAL HEALTH DIVISIIiIONI W i 445 N SAN JOAQUIN,PHONE(209)4 9I3429# P O BOX 388, STOCKTON,CA 9520 -030" Q� PERMIT EXPIRES 1 YEAR FROM E I (Complete in Triplica 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 De/velopment Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address /! / 74, ),j 1T City Lot Slie/Acreage st Phone Owns Nam Contractor Address �`t_-1A-)_- - License No.4308al-Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT r DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER ❑ Monitoring Yell ❑ 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 G industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Cis. of Well 1C� f I Domastie/Private O Gravel Pack 7) Tracy Type of Casing_ pAfN�F O I Public Ci Other M Delta Depth of Grout Seal -n Em u i i litigation __ Approx. Depth I I Eastern Surface Seal Installed by Repan Work Done ❑ Type of Pump H.P. State Work Oona_ 1994 Well Destruction ❑ Well Diameter Sealing Material L Depth �AWjGAQINTY Depth _ Tiller Material a Depth PUBLIC HEALTH SERVICES TYPE OF SEPTIC WORK, NEW INSTALLATION I I REPAIR/ADDITION LL—eeSTRUCTION I I I em parmma i public satvar n available within 200 lest.) Installation will serve: R once - Commercial L--Sher Number of living units: r of bed(ooms — N Character of sal to a depth of 3 feet: c LKl\f Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ll TREATMENT PLT. ❑ Method of Disposal Distance to nearest Well Foundation Property Line LEACHING LINE LQ-.NT.. 6 Length of lines ��..�� Total length/size FILTER BED ❑ Distance to overeat. Well Fountabon Property Line SEEPAGE PITS I%.�pth Sire Numtw SUMPS LI Distance to nearest: Well L` �Foundation 1 �20 Property Line 00 DISPOSAL PONDS ❑ 1 hereby cerlity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, end rules and regulations of the San Joaquin County Home owner or licanaad agent's signature certifies the following: "I cenify that in the performance of the work for which this permit is issued, 1 shell not employ any person in such manner as to become subject to workman's compensation laws of California. ' Contractor's hiring or suacontacting signature certifin the following: '9 certify that in the performance of the work for which this permit is issued, I shall employ pattern,subject to workmen'•componse tion IabL�of CNitorhe Thge a`rykc�a� al or W req ctioae, Complete dtowinng on reverse rid I Title Date: FOR DEPARTMENT USE ONLY Application Accepted by C. Doe Ana Z Pit or Grout Inspection by Date Final Inspection by D to 6 x3-91 Addmianal Commence' Applicant - Return all copies to: San Joaquin County Public Health Services 1` Environmental Health Permit/Services 445 N.Sen Joaquin,P.O.Bax 388,Stockton,CA 95201-0388 IN O AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BV DATf Jll EN ;324 laev ,,,,I k- ► I oo tw s.a a