COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

APPLICATION V SAN jOAQUIN COUNTY PUBLIC HEALTH �VCES �h ENVIRONMENTAL HEALTH DIVI I 445 N SAN JOAQUIN, PHONE (209) 0 P O BOX 2009, STOCKTON, CA C 9 PERMIT EXPIRES 1 YEAR FROM DAT rI ; (Complete in Triplicate ) ll\!V # a Application is hereby made to San Joaquin County for a permit to construct and/or e worm nereir 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. Job Address 6507 A z4, AiF City Oa Lot Size/Acreage S (, Owner's Name �P"f�� rP. AAd�drreess SA�*� RS tGa�JPhone �9 �00> • 4 Contractor Address a NO Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT F, Z DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIRS gOr�N S OTHERC4.. Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK >rSEWER LINES Zvi DISPOSAL J>18or PROP. LINE -00 _ FOUNDATION �Sr AGRICULTURE WELL :Pr'coor OTHER WELL >�6o PITS/SUMPS ZA6, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casi C1 Domestic/ I ate ❑ Gravel Pack ❑ Tracy Type of Casing__ Specification I'1 Public N�� I 1 Other N'� P Delta Depth of Grout Sea Type of Gro I I Irrigat n __ 4 Approx. I I Eastern Surface Seal Installed by Repair Work Done 11 Type of Pump H.P. State Work Done _ Sealing Material & Depth N �2•nC.rr �.•T Or,ZD` Well Destruction ❑ Well Diameter t, Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ' I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Pstallation will serve: Residence _— Commercial — Otf er umber of living units: Number of bedrooms haracter 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 Cl No. & Length of lines Total length/size FILTER BED N 1-1 Distance to nearest: Well _ Foundation Property Line SEEPAGE PIT 11 Depth Size _ _` Number SUMPS FJ LI Distance to nearest: Well Foundation Property Line DISPOSAL PO O 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 of California." The applicant m st all for all required inspections. Complete drawing on reverse side. •� soy �Gri•..;ts� Signed X Title: Date: �� R DEPARTMENT USE ONLY Applicatio Accepted b, _ Data Area Pit or Grout Inspection by ate ( Final Inspection by Date Additional Comments: �j Applicant - Return all copies to: San Joaquin County Public Health Services Z%..�v � Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. I �, /V EH t3-24 1REv.riHsr .�� "� ir C�-- �/ �tr� L• JJ EH 4.2e 1 'J