SU0012525 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O 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. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r Job Address 046Atsi I A) City Lot Size/Acreage Owner's Name � 6�JI I A) AddressPhone // 7 Contractor £ r Address / � �J��Li ease No.rO� 1 Z Phone —� TYPE OF WELL/PUMP: N WELL WELL REPLACEMENT Cl DESTRUCTION O Out of service Well O PUMP INSTALLATION ElSYSTEM REPAIR ❑ OTHER O Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL THEIR WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial Cl Open Bottom ❑ Manteca Die. of Well Excavation 141 11 Dia. of Well Casing 1omestic/Private Gravel Pack ❑ Tracy Type of Casing__00 Specifications I'1 Public (-I OtOt/h/yr P Delta Depth of Grout Seal �_ Type of Grout- AIrripation 4:Mpprox. Depth 11 Eastern Surface Seal Installed by ,zvd:�J:lfia Repair Work Done U Type of Pump H.P. -- State Work Done _ Well Destruction O Well Diameter :ev — sealing Material i Depth Depth Filler Material i 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 V, SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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 canities 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 cenify 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." The applicant must call for all required 01spections. Complete drawing on reverse side. r r Signed X�//.�_ !'!�L Title: �• •,, I P✓t Date: FOR DEPARTMENT USE ONLY 7 Application Accepted by Date Area V _ Pit rout spection by Date incl Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services 7z Environmental Health Permit/Services <0tr /y/1"no� 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 (/C� 4320 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO Q /y�� 2CASH . EH,}21 111 r/.sl y 17 ©° (.' , 0 EH 14.20