93-0112 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 { P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby lmade,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. 5119 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. f�j ,ob Address s CitywyI Lot Size/Acreage -7Z ` - r5' Lo e 0 5 Owner's Name %.S / 4/17tJ�j�d�i Contractor � r" �+ L�� dYess / License No. � ' " Phone -PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN ❑ DESTRUCTION [ .Out of Service Well D PUMP INSTALLATION ❑ SYSTEM REP IR 11 OTHER q Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE A: FOUNDATION AGRI LTURE WEI OTHER WELL PITS'lSUMPS R) INTENDED USE TYPE OF WELL PROBLEM A EA CON RUCTION SPECIFICATIONS D industrial ❑_Open Bottom ❑ Manteca Di of Well Excavation Dia. of Well Casing C.) Domestic/Private 1:176-ravel Pack ❑ Tracy T pe o asing_ Specifications .; 1'.1 Public (:] Dther f it Delta epth of Gr [ Seai Type of Grout I I Irrigation i ""` y{Approx Depth ,I 4I Eastern p Surface Seal Ins[ d by '4Repair.Work,Done 0 Type'of Pump„ H. to Work Done r Weft Destruction J ' ❑, Well Diameter'~ S Ing Material b Depth Depth ' Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 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 _ It Number of living,units: Number-of bedrooms Character of soil to a deplh of 3 feet: ; Water table depth- E 'SEPTIC TANK O 'Type/Mfg apacity a®o No. Compartments PKG. TREATMENT PLT. ❑ - Method of Disposa IVOAS Oi a e to nearest:a "WeFoundation ll�sa�+tL_ Fdation Property Lipe �-_0 7� 01 L NY .. "` LEACHING LINE 6 No. & Leng li of tines Total length/size FILTER BED ❑ Distance to nearest: Wall Foundation Property Line SEEPAGE PITS 11 Depth Size Number r SUMPS i Ll Distance to nearest: Well Foundation Property Line i4 ' DISPOSAL+PONDS ❑ I I hereby certify'thatAI 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 workmin's compensation laws of California," Contractor's hiring or sub-contracting signature certifies the following: "I cern at 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 mu I required inspections. Complete drawing on reverse side. i Signed / Title: Date: 43 FOR DEPARTMENT USE ONLY Application Accepted by 4 Date' �� Area ® �� Pit or Grout Inspection by �°°-�^'"""" "Date 'Final Inspection by ate Additional Comments: ..._.....,.._. - --- --�� .-,Applicant - Return.all copies to: San Joaquin County Public Health Services w.., ' Environmental Health Permit/Services I 445 N San Joaquin, P O Bbx 2009, Stkn, CA' 85201 { IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. fI EH 1324(Nev.,, n^� EH 14.20 �J ! `D© a l� Cl X _ r -