93-895 - Laserfiche WebLink

Home Browse Search

w APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BO%- 2009, STOCKTON, CA 95201 (Complete in Triplicate) 'E +Y Application Is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This 1 I applicatiori is made,itircompliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin.County_'Pupltc.Health Services. Job Address Q� City Lot Size/Acreage c� OGL _1 ' Owner's Name < LQ ^ Address 02 7 � � 65e� t-P h o n a iVV Contractor Address icense No. cw,07/3 Phone x ~TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT R DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well O r DISTANCE TO NEAREST: SEPTIC TANK Z7 2e- SEWER LINES DISPOSAL FLD. PROP. LINE e FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS10 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 74LP Dia. of Well Casing 1 Domestic/Private XGr" Pack* ❑ Tracy Type of Casing_ Specifications 11 Public th 2I 1 Other n Delta Depof Grout Seal //n /. ._ Type of Grout l J I I Irrigation 31V•Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ 11Vell Diameter Sealing Material a Depth Depth Filler Material i Depth TYPE OF SEPTIC=WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION l 1 INo septic system permitted it public sewer is �o available within 200 feet.1 Installation will serve: Residence Commercial_ Other Number of living units: Number,of bedrooms Character of sou to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG.rTREATME_NT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. a Length of linea Total length/size FILTER BED 0 c,Distanco to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size 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 licenied 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 conifios the following: "I comity that in the performance of the work for which this permit is issued, I @hall employ persons subject to workman's compensa- tion Is",It Calif nia." i The appliean st11 for afl required i spsctiona. Comple a drawing on re rse side. Signed It�e: Date: t +3 F DEPAR ENT USE ONLY Application Accepted by �} Date�1 �� Area y y Pk orrant nepection by �1[I7L• Date Final Ina ction by Date Additional Comments: ' �_Pfll odr!�, : a I Applicant - Return aJ copies to: San Joaquin County Public Health Services Environmental Health` Permit/Services F 445 N San Joaquin, P 0 Boa 2009, Stkn, CA 95201 FEEAMOUNTAMOUNT DUE AMOUNT REMITTED RECEIVED It!Y OATS PERMIT NO. + EH 1324 IREV.1/s sl EH 14"76 V !/