93-939 - Laserfiche WebLink

Home Browse Search

APPLICATION - ,- , SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 4 "" ;`ENV I RONMENTAL,PALTH DIVISION , �� 445 N SAN JOAQUIN, PHONE (20)468-A'2,0 ' �- f P O BOX 2009, STOCITON, CA 95201 PERMIT E%PIRES 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 vork herein described. This application is made in comtpliattce`,vith Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public HealthfSe�+r^�v•i$es. ' 1;ri Job Address ,� L/ ie�(✓lI� �J� f _ City ll_-GIAJ Lot Size/Acreage 'e' h k ' Owner's Name Address /�!J 7G/�aA�N��l' cf"7 . r, j Phone Contractor t. qJ61, Address AD-,AX ,l �+ y� License No.&Y'Le?_ _Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE ILIM I` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SLIMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATL ONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I') Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications Il Public 1-1 Other f-) Delta Depth of Grout Seal Typo of Grout II 11 Irrigation Approx. Depth I I Eastern Surface Seal Installed by ce R Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth ( . C%4r=Z_ Depth �S f^ r Filler Material & Depth `1 i. TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if publicisewer is st available within 2W feet.I ve: Installation will serResidenceV� Commercial,.____ Other x Number of living units: Number of bedrooms t �.. Character of Boit to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI 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 taws of California." Contractors hiring or sub-contracting signature certifies the f owing' "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 Califo►nla." The applic nt u t call for 11 requ' d i tions. Complete drawing on a rse a. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by C Date Area 9��- Pit or Grout Inspection by Dat 44a:Final Inspection by Dates Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Env tal Health 445iNoSannJoaquin, P Permit/Services Box 2009, CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CK 8 A5H . 77 RECEIVED BY DATE P7�E^RM�IT3'N EN *21 IRE .vin 51 1q17-3. 1EH4. 9O.