93-0190 - Laserfiche WebLink

Home Browse Search

4 \` APPLICATION FOR PERI[I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 Y'A 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. XJobAddress �� `�� J,�9"°ie_- City f�(.kZ,�/Lot Size/Acreage �- Owner's Name Pyr ,i 11ra7-/G'�y�� Address f�1 �{ y��rAPY�_ Phone K"C'ontractakpT' �t C�S��e y�Et36 Address 19-5-2- 6`V �Ree-_c"Ai rev License No. 2L -222e)2-Phone2,31-6(01 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AG ULTURE WELL OTHER WELL PITS/SUMPS ._ INTENDED USE TYPE OF WE L PROBLEM AREA ST TION SPECIFICATIONS A L-1 Industrial ❑ Open Bottom ❑ Manteca D' . of ►athExcaYation Dia. of Well Casing f:l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ _ Specifications Il Public I-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I tern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Wall (7iamet Sealing Material i Depth Depth Filler Material i Depth 174 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTIO (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 soli to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg Capacity No. Compartments u PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 17,1 1 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 candies the following: "1 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 unify 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 ust all for all required inspections. Complete drawing on reverse side. Spned Title: m�� Date: K FOR DEPARTMENT USE ONLY Application Accepted by Date �� Area 2 Es Pit or Grout Inspection by Date Final Inspection by 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 INFO AMOUNT DUE AMOUNT REM�ITT.ED® CASH RECEIVED BY DATE PERM17'NO. . EH IY24(REV.r i n lG� Tse- EH t�•3m1-2