93-0117 - 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 O BOX 2009, STOCKTON, CA 95201 t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby tsede to San Joaquin County for a permit to construct and/or install the work herein described. This application 1s 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 `�� C 4C � City` f /Lot^Size/Acreage =To Owner's Name > / k)r $QV Address77 Contractor Ad(IressLicense No. Phone Sce TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial O Open Bottom O Manteca "" Dia. of Well Excavation Dia. of Well Casing 171 Domestic/Private ❑ Gravel Pack O Tracy Ty (� ('1 Public Cl Other F1 Delta Depth f G ��Vrr, `�+(rv�• I I Irrigation _ Approx. Depth I I Eastern Surface Seal ` ►�Ilq�b Repair Work Done U Type of Pump H.P. ��j Well Destruction O Well Diameter Seng Material i Depth Depth Fi er Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted it public sewer is / available within 200 feet.) I Installation will serve: Residence_ Commercial_ Other J Number of living units: -- Number of bedrooms 1-- Character of sok to a depth of 3 feet: =} f+Ak4 - LC,- A' - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. a Length of lines Total length/size Q/ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth / Size,Lc�eu� 5` N 9 Number f SUMPS 1,VDistance to nearest: Well Foundation j C' f Property Line 5 DISPOSAL PONDS O 1 hereby certify that 1 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 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 compensa- tion laws of California." The applicaQLmust call for aMraqykedcoons. Complete drawing on reverse side. Signed XTitle: a <<�+ Date FOR DEPARTMENT USE ONLY 1 O, Application Accepted by * Date ` �� t� Area a Z Pit or Grout 1 r �`f-'7I.Q v a - 'its d.►.c m, 711 4 f3 Inspection by Date Final Ins ct n by ate Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit Services 445 N San Joaquin, P Box 009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY PATE PERMIT'NO. ') . EN 17 2,IREV. i N sl tQ �`-' �� 66 // EH 14-X f