COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

DPLIC. TTON SAN "IQUIN COUNTY PUBLIC HEALTH .tVICES 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 Services. t Job Address City " Lot Size/Acreage cLCYeS ct-,,faur- ;ZcZ;Iei-r t('V</t L,(t/ 31 �C�ciC y 3y� ��; tt' crac% Sireef �uc #ZCC (Zcq)144- g�30 Owner's Name Address Phone U /� eanTia; T m ➢eQ /� r•e-lu,t Izl/j (e. Z75 n 472..1 Q� oc�jarta �)O� I /l�j rEZ-ZCLC Contractor � Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION C] Out of Service 'Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER, ,QMoj�5C3ng nye ❑ DISTANCETO NEAREST: SEPTIC TANK 310CSEWER LINESc DISPOSAL FLO. "� PROP. LINE FOUNDATION AGRICULTURE WELL ' ��0� OTHER WELL ''—�` C PITS/SUMPS INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS * Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing * Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public �N Other, b&rr'11,y M Delta Depth of Grout Seal Type of Grout I I Irrigation 4��Approx. Depth I I Eastern Surface Seal Installed by r� Repair Work Done L3 Type of Pump H.P. State Work Done _ \\ Well Destruction ❑ Well Diameter &2,/ 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 U, 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size / FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number -cr SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ I hereby certify that 1 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 perrrnt is issued, I shall not employ any person in such man r as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "1 carti that in the rformance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of Califor The applicant t call Ir to ed i spe mp ete drawing on reverse srd Signed Title: • Date: L2_9— FOR O Z9—FOR DEPARTMENT USE ONLY/ / Application Accepted by Date �[ Area '6 c Pit or Grout Inspection by QQ Date Final Inspection by �p Data Additional Comments: f D / Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services Q 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE ` JQ ZE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EM ,32.1RE,.,,A„ EH 14.26 '� 89 � 83.1351