91-2969 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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 , x (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 trade in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. " KJob Address yam] • �/ � �'+��N City Lot Size/Acreage®'S Q /� .73 7A r P^G/F,6+ Owner's Name 2 S Address tD&S _9J L ISE CA-9_1,Zag_X Phone 7 S ontractor - Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications � I.3 Public fa Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —,Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done T Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth I TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION INo septic system permitted if public sewer is 1 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. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal , Distance to nearest: Well Foundation Property Line LEACHING UNE 0 No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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 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 ap -ca ire i spections. Complete drawing on reverse side, nod ,YigAR _.,._ Date: l/ ?-9,�._......_ FO ARTMENT USE ONLY Application Accepted byA < Date.-_-�r — t - Area Pit or Grout Inspection by Date Final Inspection by da Date ih Z �2 Additional Comments: / Applicant - Return all copies to: San Joaquin Coup-ti;y Public Health Services Environmenta Permit/Services 445 N S aquin, P P O Box 2009, Stkn, CA 95201 INF -1 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INF C H EH 114-28 %