93-0761 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL 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) 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 q/// gA4,N,4M,A ZA A 11445 CityS�/�^� Lot Size/Acreage Owner's Name Y Address Phone Contractor It-,Pe h/7 Address . S 4Lr_,,t_l 9 S L/� License No. '. X74 Phone ,39 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial O Open Bottom Q Manteca Dia. of Well Excavation Dia. of Well Casing [:1 Domestic/Private O Gravel Pack ❑ Tracy Type of Casing_ Specifications I'l Public I.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 U Type of Pump H.P. _-- State Work Done _Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION A REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is / available within 200 feet.) Installation will serve: Residence "/ Commercial_ Other Number of living units: ---/— Number of bedrooms Character of soil to a depth of 3 feet: X Water table depth SEPTIC TANK O Type/Mfg p4-1- Capacity / C70 No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well t;_r 0- Foundation 7-421 � Property Line 15.1 LEACHING LINE L91 No. & Length of lines -3 '&C Total length/size 0 FILTER BED O Distance to nearest: Well -Ty"f' Foundation ".01 Property Line SEEPAGE PITS It. Depth 9.5 ➢ Size 0�1 2. Number 13 SUMPS LI Distance to nearest: Well /C!G'J t- Foundation .Sty Property Line DISPOSAL PONDS O 1 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 which this permit is issued, I shall no 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 applicant must call for all required inspections. Complete drawing on reverse side. , Signed X e /`l/>PryTitle: Date: .�/ FOR DEPARTMENT USE ONLY Application Accepted by .r --a7�d� Date �- Area or Grout Inspection by ✓ Date=F=�---f9 Final Inspection by �. ✓ DateV_-2.2 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 I CK 11 RECEIVED BY DATE PERMIT'NO. INFO / /} ` CASH 2 �( • EN 3-24 EH141atREV.rin51 7 L N� / /��0 �. 7 ,J rtJ 79