SU0005873 SSCRPT - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES " ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 20'09', STOCKTON, 'CA 95203. I i PERMIT EXPIRES 1 YEAR FROM DATE ISSUID i (Complete in Triplicate) i i Applicatioti is hereby made t.0 San Joaquin County for a permit to construct and/or install the work herein described. This 1 application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public �Heeaallth Services. r . Job Address ' �✓ `vct(''sv -'�� "� City e-$ Lot Size/Acreage y] • �f j Owner's Name cs ^ Address) �� Phone Contractor r�7t "'" " - Addres�) i/—[ '1� � ' ,C�3 _ License No. G Phane b,f TYPE OF WELLIPUMP: NEW WELL ❑ !WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Weil ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS F iNTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca I Ria. of Well Excavation Dia. of Well Casing i Ca Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_. Specifications I'1 Public CI Other Cl Delta l Depth of Grout Seal Type at Grout T I I Irrigation _Approx. Depth 1 I Eastern i, Surface Seal Installed by 3 Repair Work"Dane U Type of Pump H.P.f State Work Done ` Well Destruction ❑ Welt Diameter Sealing Material 6 Depth } " Depth Filler Material & Depth INSTALLATION ! I EPAIR 1ADDITiON I I DESTRUCTION I I (No septic system permitted if public sewer is TYPE OF SEPTIC WORK: NEW INSTALL �A ! available within 200 feet.) i Installation."ll serve: Resi fdence✓ Commercial— Other i? Number of;living units: r--- Number of bedrooms ; Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments '1 PKG. TflEATMENT PLT. ❑ Method of Disposal j Distance to nearest: Well Foundation Property Line F LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED: ❑ Distance to nearest: Well Foundation Property Line !` SEEPAGE PITS 1 1 Depth a Ja -- �V - Size � VX1 Number SUMPS LI Distance to nearest: Well^1404Foundation �/�'��_ Property Line DISPOSAL PONDS 0 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 j Home owner or licensed agent's signature certifies the following:.('l 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 taws 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." L a 'j The applicant mus c I for all required inspections. Complete drawing on reverse side, 4 Signed X� .. e%'!/t*r .✓a/r' -- Title: �YvhC2rr _� Date: i FO DEPARTMENT USE ONLY F Application Accepted by� ��^ - " Date Area Pi r Grout Inspection by l Dater/ Final Inspection by Date lY � Additional Comments: r � Applicant - Return all copies to: San JoaquinlCounty Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 I l )NFO AMOUNT DUE AMOUNT REMITTEE CASH RECEIVED BY DATE PERMIT NO. / EN 13-24 1ACV.I/n 5 EH 14.76 0 ! VVV