93-0373 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES = . ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEM F&QM DATE ISSUSP (Complete in Triplicate) Application is hereby made to Sam Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City Lot Size/Acreage ;270 r ' Owner's Name ress Phone Contractorj2Address License No. ZZ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Nonitoring Well n DISTANCE TO NEAREST: SEPTIC TANK - SEWER LkNES DISPOSAL FLD. PROP. LINE FOUNDATION -AGRICULTURE WELL '-OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom C1Manteca Dia. of Well Excavation; ....__ Dos. -Wall Casing Cl Domestic/Private ❑ Gravel Pack ' '❑ Tracy Type of Casing— "� Specifications.. I'1 Public Cl Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern" , Surface Seal Installed by �� •• — f M Repair Work Done LJ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diaeter Sealing Material i Depth Diameter Depth Tiller Material tL Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIWADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 lest.) Installation w41 serve: Residence_L__ Commercial— Other Number of living units: . }_ Number of rooms Character of soil to a depth of 3 fest: Water table depth .+ SEPTIC TANK ❑ Type/Mfg _ -�, Capacity No. Compartments PKG. TREATMENT PLT. D T t I Method of Disposal I Distance to nearest: Wel I Foundation Property Line r - LEACHING LINE Cl No. 6 Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well j� Q b - Foundation Property Line SEEPAGE PITS ( I Depth r -Size - - ' Number LI Distance to nssrest: Well Foundation-& — Property Line 190 DISPOSAL PONDS a 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 licensed agent's signature certifies the following: "I certify that in the performance of the work for whOch 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 hir"in -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 b workman's compensa- tion laws of California." The applicant must II for 80 ad I spections. m to drawing on reverse side. 1' f Signed17 Tktle: Date: / FOR DEPARTMENT USE ONLY a Application Accepted by Ed Ala ,�"^ - _ Date 3 N�r,n,`,A��}� Area _ 2-12— 14C) IP Ph or Grout Inspection by Data Final Inspection by ,ivy Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK ARECEIVED 0Y DATE PERMi7'NO. rj. INFO CASH !T + EH ii�p lREv.r/A sl 5 l✓ /t` v 0:?-0 r/