SU0004195 SSNL - Laserfiche WebLink

Home Browse Search

' APPLICATION SAN jOAQUIN COUNTY PUBLIC HEALTH ENVIRONMENTAL HEALTH DIVISO K�[� 445PNOSB XJOAQUIN, PHONE 2009, STOCKTON, CA 6$;�4 PERMIT EXPIRES 1 YEAR FROM DAT (Complete in Triplicate) NV # O1 Application is hereby made to San Joaquin County for a permit to construct and/or install t application is made in cccq)llance with San Joaquin County Ordinance No. 549 and 1 2 and the Rules and Regulations of San Joaquin County Public Health Services. n Job Address . V • 1/- �t�C�y!'ir �CJ�. City `-c 'G� Lot Size/Acreage 1 o Z� A�`( S Owner's Name bl'`U Address �?1� t/U L�Ci+i/.�lYl' flf X;�Al Phone _ I (17 Contractor y Address a( ,. (�lCf�l�`�, � License No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTI NK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A CONSTRUC IFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ell Excavation Dia. of Well Casing Cl Domestic/Private Ell Gravel Type of Casin Specifications I.1 Public 1.1 Otheta Depth of Grout Seal Type of Grout I I Irrigation —Aptern Surface Seal Installed by Repair Work Done U T of Pump H.P. State Work ne_ Well Destruction ❑ ell Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence X Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: r ��j Water table depth SEPTIC TANK Type/Mfg Capacity v No. Compartments -Q- ^� PKG. TREATMENT PLT. O _ Method of Disposal v Distance to nearest: Well n� Foundation Property Line /� LEACHING LINE :C No. 6 Length of lines - 110, L,i2P � c /� Total length/size FILTER BED ❑ Distance to nearest: WellFoundation Property Line SEEPAGE PITS 11 Depth Size� x, ar J 1 � f Number �� K, SUMPS Distance to nearest: Well 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 t following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person insuch man to become sub t to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies t wing: "I can, that in he performs e f the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion la of Call or The�plicant m st all f a requir ins m ete drawing on r ver�ide. !/ Sig Title: _ /f7/ /'IY t�C�'l Date: 7 FOR DEPARTMENT USE ONLY Application Accepted by Date Area 1-Z/ Pit or Grout Inspection b _ Date nal Inspection b1y� G-- Date m 3 Additional Coments r1 o�r c.� hc, cfk_ , Applicant - Return all copies to: San Joaquin County Public Health Services f Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE INFO AM/OUNT DUE AMOUNT REMITTED CASH � RECEIVED BY DATE PERMIT NO. EH 13-24 lN(:V.s i M er EH 1t-14-25 / �— I! '� CP 5 r J