92-0025 - Laserfiche WebLink

Home Browse Search

Y APPLICATION FOR PERMIT W\ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' i1 ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ` PERMIT EXPIRES I YEM 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. 51+4 and 1$62 and the Rules and Regulations of San I Joaquin County Public Health Services. Job Address ' 149"City&A C4-- Lot Size/Acreage �ZIE,6 Owner's am 'ivy Address I?3��C}!N�l1716� Sal/ tom{_/� Phone V ; (�J� Cot actors 091-44N6= Address `S• kf a se N Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well O DISTANCE TO NEAREST" 'SEPTIC TANK SEWER LINES DISPOSAL FLD= PROP. LINE FOUNDATION AGRICULTURE WELL- OTHER WELL `Y PITS/SUMPS �~ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom @`+Manteca Dia. of Well Excavation Dia. of Well Cad' f.1 Domestic/Privet* Gravel Pack E3 Tracy Type of Casing'4' ,16 - _- Specifications >-12,ublic 1-1 Other f1 Delta Depth of Grout Seal JQ21y: Type of Groug S I I Irrigation ,!2P Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth filler-Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l 1 (No septic system permitted it public sewer is ' available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units. Number of bedrooms P n Character of soft to a depth of 3 feet: Water table depth LJ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. 6 Length of lines Total length/size FILTER BED ❑ Distance to dearest: Well Foundation Property Line SEEPAGE PITS 1I. Depth Size Number r 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, 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Coniractor's.hiring or sub-contracting signature certifies the following: "I cartify 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 fo all requi I tions. Complete drawing on rse sid r �— Signed Title Date: ?44 �� - frx FOR EP MEN USE ONLY r-� Application Accepted by Date Area Ph or Grout Inspection by Date Final Inspection by Data p Additional Comments: �o o11 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 H San Joaquin, P O Box 2009, Stkn, CA 95201 Y FEEFAMOUNTDUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO.INFOCASH EH 13.241REV.1i1r5d il`? C7 G .. EH 14.29 I6� -