93-0598 - Laserfiche WebLink

Home Browse Search

r r I r APPLICATION FOR PERK[I T SAN -JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 R P O BOX 2009, STOCKTON, CA 95201 PERMIT 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 eompliance,with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address —_ _ Citvkdos` Lot Size/Acreages I' Owner's Name �64ZE` _/ .� Address Phone 7 /7+�I�2" Contractor Address License �7"/ ho i 0 Nd� Phone TYPE OF WELL/PUMA: NEW WELL ❑ WELL REPLACEMENT [-1r, DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR p OTHER O Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER.WELL - PITS/SUMPS INTENDED USE TYPE OF WELL r PROBLEM AREA CONSTRUCTION SPECIFICATIONS L) Industrial ❑ Open Bottom. ` D'Manteca Dia. of Well Excavation, Dia. of Well Casing EI) Domestic/Privet* ❑ Gravel Pack ❑ Tracy Type of Casing_ f Specifications 11 Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigatlon _Approx. Depth 11 Eastern Surface Ssnl Installed by .Repair Work Done L7 Type of Pump H-P, Stats Work Done_ Wall Destruction 0 Well Diameter Sealing Material i Depth Depth filler Material i Depth ' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 4/DESTRUCTION I I (No septic system permitted it public sewer is � 3 available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: .•,_ Number Character of sort to a depth ►f 3 feet: Water table depth SEPTIC TANK Typs/Mfg ' Capacity a, No. Compartments PKG. TREATMENT PLT.0 /� : o Method of Disposal Distance to nearest: Well A-4Foundation �� `A Property Line t t , LEACHING LINE CI No. & Length of lines Total length/size FILTER BED ❑ Distance toynearest: Well Foundation--- Property Line s 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 Homs 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 laves 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)awe of California." i. # The appliescall or all rpi1$i1koonspeolons. Complete drawing on reverse side, 'e 1 Signed Title: Sate: 1 I FOR DEPARTMENT USE ONLY 3 Application Accepted by Date �+ Area ,6 �� t _ -S _ 3 �3 Pit or Grout Inspection by_ Data Final lnspecti n by pate/ I Additional Comments. -rJF� s j Applicant - Return all copies to: San Joaquin'County Public Health Services • r Environmental Health Permit/Services 1 445 N San Joaquin, Box.2009, Stkn, CA 95201 FEE SINFO AMOUNT DUE AMOtlN REMITTED K ECEIVED BY DATE PERMIT'NO. a EK 15-24IN&.f/R51✓� F �! [ _Q �� EH 11.2e iii"' 6qE:L�� J �