93-2063 - Laserfiche WebLink

Home Browse Search

APPLICATION $ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 1 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 Application is hereby made to San Joaquin County for a permit to construct and/or install the Work herein described. This iii 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. J & f!-. _ City _L�r/ ..� Lot Size/Acreage Z- Job Address r �a ��, Phone Owner's Name � ® Phone o ,,-,e� / C(f, t5r �icense No. Phone� �ZG Contractor ddress [ _,_� — — rvice Well TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out Monitoring Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Lf SEWER LINES C DISPOSAL FLD. PROP. LINE _ FOUNDATION /I� —_ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !I L} industrial. ❑ Open Bottom D Manteca Dia. of Well Excavation _ 1,0 - _,— Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ �VL - _ Specifications p V1 Public [-1 Other n Delta Depth of Grout Seal Type of Grout 11 Irrigation _Approx. Depth -l-1 asiefn Surface Seal Installed by � Repair Work Done U Type of Pump H.P. State Work Done Sealing Material & Depth Well Destruction ❑ Well Diameter Piller Material & Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION { I DESTRUCTION I I INo septic system permitted if public sewer is ern 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 t Capacity No. Compartments SEPTIC TANK ❑ 'Type/Mfg j PKG. TREATMENT PLT. ❑ Method of Disposal j Distance to nearest: Well Foundation Property Line k k I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well' Founaatian Property Line a SEEPAGE PITS 11 Depth Size Number * . . . F SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ 1 hereby certify that 1 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 iignature 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 applicant cal o squired ins ctions. Complete drawing on reverse side. Signed X Title " ""9� Date: FOR DEPARTMENT USE ONLY Application Accepted by 1 Date f f Aread --- 7 Pit or Grout Inspection by .' __ Date loh 2/-q�L Final Inspection by Date V Additional Comments: Applicant - Return all copies to. San Joaquin County Public Health Services 01 Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIVN0. INFO ? . 0s o r EK13.24IREY.r/nW EK 14.71 L