SU0000817 - Laserfiche WebLink

Home Browse Search

�# .vrt L APPLICATION `- - AIDAN iN COUNTY PUBLIC HEALTH SERVICES 144 5 ? f? / 7i,, 7� I RONIIENTAL HEALTH DIVISION / ", `7 �J 7� AN JOAQUIN, PHONE (209)468-3420 FAC# I/ PERMIT O BO% 2009, STOCKTON, CA 95201 NV#TNV Jt'�S`-� PEIT 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. Job Address .! 7� 7D�1/5n wA �7 City� Lot Size/Acreage -`1257--f� Owner's Nam e/L:etu/e 7'� y 14h � 41�/ Address 2-7.10, 740 /y.. 5,!0 w/2_ S. /ri// Phone Contracto✓ 1!— -Address/--' 2--ZLicense No.� Z�ti Phone -F-"Z,01LZ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION L SYSTEM REPAIR L OTHER ❑ Monitoring Well DISTANCE TON T: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE TION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL BLEM AREA CONSTRUCTION SPECIFICATIONS CI Industrial O Open Bottom L-1 Manteca Dia. of Well Excavation Dia. of Well Casing C 1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type ing — Specifications I'l Public f ] Other I? Delta Depth of Grout Type of Grout i IrnUsuon __ Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. _ State Work Don Well Destruction O Well Diameter _ Sealing Material & Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK. NEW INSTALLATION ' I REPAIR.'/�DOITION i I DESTRUCTION I I (No septic system permitted if public sewer is Glq�"/D N5 7`S ( , — available within 200 feet.) Installation will serve: Residence_ Commercial _ er — Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O 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 1-I Distance to nearest: Well Founaatron _ Property Line SEEPAGE PITS 11 Depth Size _._ Number . SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 workmen'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 applicam I must call fo required inspections. Complete drawing on reverse side.�-/ Signed ��OZv-�� Title: 1A �79/�1F-'r2/�- Date: /2"/ /3 FOR DEPARTMENT USE ONLY Application Accepted by _ _ Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: _(, Applinant - Return all copies to: San Joaquin County Public Health Services t/ 7-,)C/y 5a Environmental Health Permit/Services )C 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. Z.13-241AEV.i/Abi I OV1'l I EN 14.26 166 &0��