93-0057 - Laserfiche WebLink

Home Browse Search

r 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 L, City �"'"� Lot Size/Acreage Owner's Name I 0 ` Address /d,_I QA�y► yh Qom_ Phone 36A?4FQ Contractor V AddresslP Vfo t[ E`�`1' h License Nqt l&��Phone 1��lAr TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well 15— PUMP PUMP INSTALLATION O SYSTEM REPAIR O OTHER ❑ 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 CI Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C:l Domestic/Private O Gravel Pack ❑ Tracy Type of Casing_ Specifications 1'1 Public fl Other n Delta Depth of Grout Seal Type of Grout eIrrigation _.Approx. Dept I I Eastern Aurface Seal Installed by Repair Work Done 0 Type of Pump H.P. d State Work Done Well Destruction O Well Diameter Sealing Material & Depth \l Depth Filler Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I iNo 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: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation 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, an 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: "1 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 applica t must call for 11 required inspections. Complete drawing on reverse side. et Signed X_ /""Title: s� Date: F R DEPARTMENT USE ONLY Application Accepted by W AQrta Date Area Z t Pit or Grout Inspection by Date Final Inspection by Data Z— 0 Additional Comments: ( 77 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P ox 2009, Stkn, CA 95201 IN AMOUNT DUE AM UNT REMITTED I. CAS RECEIVED BY TE PERMIT'NO.') . EH 13.24(REV.1/RSl EH 14.26