SU0004516 SSNL - Laserfiche WebLink

Home Browse Search

SAN _. AQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 Service�� H % � Job Address e ,rte Cit Lot Size/Acreage 1'-l7.`c) xgo iktOwner's Name t `szTf�ss �J w Phone 1`I 7 'IQ Contract rte, f 1 , Address Vo.R_77k License No z ZZ�' Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C 1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ _ Specifications Cl Public 1.1 Other fl Delta Depth of Grout Seal Type of Grout f i I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth rial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I EPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: I Number drooms Character of soil to a depth of 3 feet: ` A& Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well _ Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well F dation Property Line f SEEPAGE PITS 11 Depth lS Size — Number I SUMPS Distance to nearest: We r 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 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 oalifornia." The applican m t call for req r inspections. Complete drawing on reverse sid Signed X Title: z ` Date: FOR DEPARTMENT USE ONLY Application Accepted by � .ell Date —3----F Z Area . 1t or Grout Inspection bt —T 4 Date/ L- Final Inspection by /' /_ Date Additional Comments: p Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P Oox 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTE CK ECElVFP BY DTE PERMIT NO. INFO // EH 13-24 IREV. EH 14-26 !!! VVV LJ r