93-0567 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 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 In hereby made,to San Joaquin County for a permit to construct acrd/or install the work herein described. This application in 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 �3 �'' City Lot Size/Acreage �h ly / 3.Z. Owner's Name Address _ � �� Phone 19~ Contractor 4Gf/�I '' Address - License No.J Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION El SYSTEM.REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fl Domestic/Private 0 Gravel Pack7,. ❑ Tracy Type of Casing_ Specifications l'I Public 1"3 Other f1 Delta Depth of Grout Seal " Type of Grout I I Irrigation _.Approx.,Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Wall Destruction O Well Diameter Scaling Material i Depth f a Depth biller Material Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTIO I (No septic system permitted if public sewer is l available within 200 feet.l 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 0 Type/Mfg Capacity No. Compartments _S_ PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. 6 Length of lines Total tength/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 subcontracting signature certifies the following: "I 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." k'sig The applicant must call for all required i t' . Complete drawing on reverse side. C� Q ned Title: — ---- l/✓f1� Date:' FOR EPARTMENT USE ONLY �f7 Q f , Application Accepted by ___— A.An� Date T "�S T Area C2� �t Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: f 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMMNO. . E1}21fREY.��w57 r 7 O EHN ' '7VA L J�g �5 / 11.26 d t7 y E�