93-0362 - Laserfiche WebLink

Home Browse Search

I� APPLICATION FOR PERMIT 4 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENV IRONMENTAI; HEALTH DIVISION 445 N SAN JOAQUIN PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I � I I� 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �}`� • Cit yy ,rgps�_ Lot Size/Acreage Owner's Nam Address `4, 11tLW Phone \14 IF Z3&0[., f��4�Nc,Contractor Address a , Phone TYPE OF WEL M : NEW WELL ❑ WE L REPLACEMENT n DESTRUCTION 0 Out of Service hell 0 PUMP INSTALLATION ❑ SYSTEM REPAIR p OTHER &t. Monitoring Yell ❑ DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES !k DISPOSAL FLD. PROP. LINE II. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca Dia.` of Well Excavation Dia. of Well Casing i 36 Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing- Specifications Il Public f-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth / I I Eastern Surface Seal Installed by Repair Work Done 16 Type of Pump�Q,{.� H.P.1 11, _ State Work Dor'. .�[ J Well Destruction ❑ Well Diameter Sealing Material i Depth :II" Dep;p II' Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system pormitled if public sewer is 0 ! available within 200 feet.) `. Installation will serve: Residence Commercial Other ` Number of living units: Numbei of bedrooms P YMENT Character o1 I�to a depth of 3 feet: I Water SEPTIC TANK - ❑ Type/Mfg JI - Ip Capacity No. Corn mentC ' PKG. TREATMENT PLT.❑ Met flod tlF'Dfsposall Distance to nearest:" Well Foundation Property L W S�RVkCES - 1Ct510N LEACHING LINE C) No. b Length of lines �� Total length IRal,1 FILTER BED MI fl Distance to nearest: Well Foundation Property Line SEEPAGE PITS"` I I Depth Size I. t _ I, Number y SUMPS -LI Distance,to nearest: -Welly Foundation Property Line -yam 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 roqulations 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 which this permit is issued, I shall not employ any person in such manner as to become subject to workmen'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 compen"- tion laws of California." II. Thea li applicant must call for ail r 'ed inspections. Complete drawing or .verse side. Signer X Tiile' Date:, ha t i!� EPART NT US Application Accepted by I Date as Pit or Grout Ins Ip�f coon by I! Date ! Final Inspection by Datil✓ d Additional Cam ! nts: ) Applicant - Return all cogies'to: San Joaquin County Plublic Health Services I Environmental Health Permit/Services p 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 :k , FEE MOUNT DUE I, OUNT REMITTED CK RECEIVED By D TE PERM17•No. In EH 13-21 IREV•i i n KV11 EH 11.26 Eli }