92-3640 - Laserfiche WebLink

Home Browse Search

a� 3; APPLICATION FOR PERMIT �j 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 1s hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. w. /y� Job Address /301 F s��ti� City ✓ r Lot Size/Acreage Owner's Name `� I�I�ITL'ra Address e Phone?,67-S101P L Contractor </i4 GEOW Addresp(J /.x/78" License No3=r-f�Phonel+ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION t of Service Well 0 PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well ❑ 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 _ 0 Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing p ,� Cl Domestic/Private O Gravel Pack O Tracy Type of Casing_ Specifications Q (1 Public fel Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by r Repair Work Done U Type of Pump H.P. State Work Done_ We® Destruction ,'.0e Well Diameter Sealing Material i Depth t�"<*tS&, y ` Depth 7e0 Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted it 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 fat: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments V' PKG. TREATMENT PLT.O 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 11 Depth Size Number ww SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O t _ 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 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant mustps#forA regwirr Inspections. Complete drawing on reverse side. Signed X f�� AeA,_ Title: Date: R DEPARTMENT USE ONLY Application Accepted by a 14 - an 3ae��y Date Area Pit or Grout Inspection by Date Final Inspection by Date 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 E16 AMOUNT DUECK AMOUNT REMITTED A�CASHRECEIVED®Y DATE PERMIT'NO. EN 17.21(IIEV.r i n 5) t �' iC'^Q A7 I �J`-7-7�EN 1l•7l1 V �P" �,2