SU0003156 - 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 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. Its application is made in conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County b is Health Services. ll Job Address C �^ City Lot Size/Acreage Owner's Name +� `' /✓ '� ��/{dl�i`(Address Phone Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [-I DESTRUCTION CI Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_.._ Speclfi�cations I') Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —_ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material L Depth Depth Filler Material Z Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it 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: f Water table depth 'a SEPTIC TANK ❑ Type/Mfg dJC-C r Capacity AWe 1 No. Compartments PKG. TREATMENT PLT. ❑ � Method of Distance to nearest: ( Well` foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED Cl-- Distance 16 clearest: Well Foundation Property Line SEEPAGE PITS I I`-Depth Size - _ Number SUMPS LI Distance to nearest: Well Foundation Property line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and thal the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and isduletions of the San Joaquin County r 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, 1 shell 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 1o►which this 158rmit,is issued, I shall employ personi subject to workman's compensa- `jtion laws of.Californla." ` The applicant must call for all required inspections. Comp11110 drawing on reverse side. y Signed X Title: Date: R DEPARTMENT USE ONLY Application Accepted by bete Area 7t Pit or Grout Inspection ate ii Final Inspection b`y Date j Additional Comments: Applicant - Return all copies to: Sin Joaquin County' Pitblic Health Services Environmental Health Permit/Services 1 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEEA MOUNT DUE AMOUNT REMITTED CK If RECEIVED BY DATE PERMIT NO. INFO CASH i EH 1324 IREV.vas) \? . EH 14'120 t r �w w