93-817 - Laserfiche WebLink

Home Browse Search

" h APPLICATION FOR PERMIT �I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIROMIENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 PP O BOX 2009, STOCKTON, CA 95201 Il PERMIT EMIRES 1 YEAR FROM DATE ISSUED 1 (Complete in Triplicate) Application is hereby tmde to Sab Joaquin County for a permit to construct and/or install the work herein described. This application is made in oonpliance with San Joaquin County Ordinance Ro. 549 and 1$62 and the Rules and Regulations of SanJoaquin County Public Health Services. '_Job Address 96Sb " Q_" CA-U-)a ; City Lot Si ze/Acreage ✓Owner's Name d1 Address ,"06 Up RT Phone ,, Ontractor -U tt1 Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Mtonitoring Well 0 " DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WE L -OTHER'WELL�� "-'- PITS7_SUMPS-_;!__ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I.1 Public fl Other ` Fl Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approxi Depth I I Eastern Surface Seal Installed by _ Repair Work Done 0 Type of Pump H.P, State Work Done Wall Destruction Destruction O Well Diameter" Sealing Material i Depth Depth Tiller Material ti Depth j TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTID I (No septic system permitte ublic sewer is H. ! .- vtilable within 204 , Insta will terve: Residence Commercial_ Other Number of IhAn a: Number of bedrooms Character of soll to a dep 3 feet: s Water table depth. SEPTIC TANK. ❑ T 1 r `'""`"'� YDeI city No.�Co7npartments PKG. TREATMENT PLT.❑ !I { '' Method of Disposal Distance to nearest: Well Foundation on. ' ' Property Line + LEACHING LINE ❑ No. G Lengt Ines rel length/size i FILTER BED ❑ Dist to nearest: .Well j Foundation rty Line 0 � SEEPAGE PITS I I Depth ld' Sire Y Number t SUMPS Ll Distance to nearest: Well R __m. Foundation- „Rroperty._Li-r 9 DISP L PONDS ❑ sreby certify that I have prepared this:�apphcation and that the work will be done in accordance with San Joaquin county ordinances, state laws, an I rules and regulations of the San Joaquin County Hama owner or licensed agent's iignsture 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 f -ng: "I certify that in the porformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of all ornla." The appy nt st tail f r all r ired inspections. Complete draw' reverse side. # .--'Signed �I Title. _ -- ., Data: ✓ L�� _ F R DEPARTMENT USE ONLY p l �' Application Accepted by " Date A►aa 1 Pit or Gout Inspection by I� Oats Final Inspection by Date la I Additional Comments: 4 � t -Applicant - Return all copies to: San Joaquin-Co`un'ty-Publ-i.c,-Health-Servi'ces'�--- Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE i INFO AMOUNT DUE �� AMOUNT REMITTED HK/1 ECEIVED BY DATE PERMIT'Nt).F, . Elf EH13.24 IR7/a 5) 74. IRM