93-0163 - Laserfiche WebLink

Home Browse Search

it APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 3� P O BOX 2009, STOCKTON, CA 95201 2 PERMIT EXP i RES 1 YEAR FROM DATE I SS]TED Il (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 coeiliance with San Joaquin.County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. i, c Job Address City t Size/Acreage �._..!-o - w, i Address.; _ _.....-. ...— --._ . ..Phone.3 33 Contractorddress nd J License No.[ 313 Phone .2 TYPE OF WELL/PUMP: NEW VVELL ❑ WELL REPLACEMENT n DESTRUCTION Ci Out of Service Well Gl fi PUMP INSTALLATION ❑ SYSTEM IR ❑ OTHER ❑ 18onitoring hell ❑ DISTANCE TO NEAREST: SEPTIC TANK SEW R LINES DISPOSAL FLD. PROP. LINE , `tF FOUNDATION AGRI ULTU WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS C7 industrial ❑ Open Bottom ❑ Monte rD�iar of WeII Excavation Dia. of Well Casing C7 Domestic/Private ❑ Gravel PackZ11 Type of Casing- Specifications i'l Public C7 Other Depth of Grout Seal Type of Grout I I Irrigation ._.--Approx. Dern Surface Seal Installed by Repair Work Done U Type of PumpH. 1State Work Done ` \� W611 Destruction ❑ Well Diameter Ing !liaterial i Depth �V Depth �'!i ler bliterial i Depth TYPE OF SEPTIC WORK: NEW INSTALLAT40N M. REPAIRIADDITION i I DESTRUCTION I 1 INo septic system permitted if public sewer is Ij ✓/ ,rf "'�" available within 200 feet.) i installation will serve: Residence_._ Commercial Other` E t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: m--- Water table depth SEPTIC TANK. ❑ TYpelMfg F - Capacity_L______V_ No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: -Well FounVationy, Property Line-2--k-0 -11 t LEACHING LINE Cl "No:�i Length of`linea length/size s °f FILTER SO : ' 0 Distance to nearest: Well Foundation Property Line R'3ti SEEPAGE PITS 1 I Depth Number i' SUMPS LI Distance to nearest: I Fou tion arty Lina 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 sub-contracting 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." The applicant st call for uired I pections. Complete drawing on reverse side. E i Signed c Title: — --_-_ _ Date: —.2 I I 'I FOR DEPARTMENT USE ONLY Application Accepted by Date �-,2 Area / fJew Pit.or Grout Inspection by I FAData Final Inspection by A A A4 Date Additional Comments.• It h Applicant - Return all copies to: San Joaquin County Public Health Services i Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE �i NFO AMOUNT AMOUNT DUE AMOUNT REMITTED K RECEIVED 9Y D TE PERMIT'NO. . EH ts•T/!'(REV.iinsr ,y t'H l�da� +s.