93-0102 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �-- ENV I RONMENTAL HEALTH DIVISION 0 � 445 N SAN JOAQUIN, PHONE (209)468'-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES Z YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby ttlade.to San Joaquin "County for a permit to construct and/or in the work herein described 'Bila application is made in cowpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. o Job Address 1 v c /c City Lot size/Acreage /Os -5 0_ Z Owner's Name L fr?IIV� Address � 2�i G -ReL��I� ._._— Phone ile _T Contractor �. Addres7L_ License No. —Phone TYPE OF WELL/PUMP: -NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION E) T _SYSTEM REP �M OTHER ❑ fhloaitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE"'" 'l FOUNDATION GRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRQBLEM EA CONS UCTION SPECIFICATIONS n Industrial C] Open Bottom ❑Manteca Dia. f Well..Excavation Dia. of Well Casing F1'Oomestic/Private C1 Gravel Pack Tracy _pe of Casing_4—'s Specifications i'1EPtiblic (D Other Delta Depth of G,out!Seal Type of Grout r, 1 I I.1rrigation Approx. Depth I Eastern Surface Soul Installed by Repair Work Done LJ Type of Pump P. State Work Done Well Destruction ❑ Well Diameter Sealing Material A—Depth . l Depth Filler Material i Depth - , . TYPE OF SEPTIC WORK; NEW IN$TAl�LA710N I I REPAIR d-::DESTRUCTION INo septic system permitted it public sewer is J available within 200 feet) Installation will serve: Residence_K_ Commercial _� Other , ., Number of living units: Number of bedrooms - I Character of soil to a depth of 3 to P t Water table depth SEPTIC TANK ❑ TypelfNfg 1" No. Compartments �\ PKG. TREATMENT PLT. L'3pp�1�t+9� Method of Dittprys�ii Distance It�r�etEsi4 ,�t�r��r��lT'f'r Property Line 13 _ _Wntle hoin. i LEACHING LINE ❑ Na & Le (h 4�ngs ` Total"length/size 3 F 'FILTER BED n Distance to le Or 111specfed Tas Min ' Property Line 1.1 F7 SEEPAGE PITS I I '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 - . _ i Home owner or licensed agent's signature certifies tho-follbwin6i "I certify they 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 cenify 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," f The applicant ust tali for all requir inspections, Complete drawing on reverse side. j 2 Sigried X Title: SneSbt F-�� Date: / °r D PAR ONLY Application Accepted by Date " Area Pit or Grout Inspe tion 6y Date Final Inspection by Data Additional Comments:~ Applicant Return all copies to: San Joaquin County Public health Services Environmental Health Permit/Services 446 N San Joaquin, P O Box 2009, Stkn, CA 95201 r - INFO JJ77AMOUfJT DUE AMOUNT REMITTED AS��ii RECEIVED BY DATE PERMIT'NO. p . EH 13.24IAEV,i145) SD EH 14-21