93-0204 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION //A 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 11-1 S)C) ��J ` I11J Ack City Lot Size/Acreage Owner's Name DAN Address SA' "— ^ Phone Contractor /� e#Jok a Address 1 !50 8U� ^f1/eLicense No.24JZ3- �BPhone 62,3 -6se TYPE OF WELL/PUMP: NEW WELL ❑ WELL.REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ S*MTEM REPAIR 0 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 n Industrial ❑ open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications (1 Public El Other n Delta Depth of Grout Seal Type of Grout t I I Irrigation _.Approx. Depth ( I Eastern Surface Seal Installed by �r Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION Ir DESTRUCTION Ir_ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Reside ce_Z Commercial Other Number of living units: Number of Aodrooms Character of soil to a depth of 3 feet: �� r1 Water table depth SEPTIC TANK O Type/Mfg EL Capacity_ e5U No. Compartments - y PKG. TREATMENT PLT. ❑ G , C t Method of Disposal Distance to nearest: Well 5 Foundation J Property Line 2 LEACHING LINE L<No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I•I'--Depth Size _ Number f SUMPS LI Distance to nearest: Well OFoundation . t Property-Line 6� 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 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 beco subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies the following: "1 certify that in the pert mance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m all for all r ins ions. Complete drawing on re arse side. 9 r Signed X W"� Title: Date: 2 " _ `7 FOR DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspection by _._ Date_/_ Final Inspection by Dated Additional Comments: Applicant - Return all copies to: San Joaq,;__ County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT'NO. INFO 11 { } CASH / g . EH 1324MEV.1i95) r 'M-(, i r t")--" EH 11.26