93-207 - Laserfiche WebLink

Home Browse Search

A_�PL•I C..AT T f�Id I Y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE �� q ENVIRONMENTAL HEALTH DIVISION 4PHONE 209)468-3420 *6 Soilllrngs to 445 N SAN JOAQUIN, EB ��g3 p O BOX 2009, STOCKTON, CA 95201 F E Bmlxfl W3 depth, 1 temporary well for PERMIT EXPIRES 1 YEAR FROM DATE I SSU NVIRO"EN?Aa�kT[i test. ENVI�NME�AL HEALlI� (Complete in `Triplicate) PERMIT/SERVICES " i fERM11!SERVICES Applicat on 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 end Regulations f San Joaquin..County Public He It services. + , tr g w- Q- � 1 r _SharpLe city ; .Lot Size/Acreage 1400tx400' tionPra ram We, Job Address Def nse i " U S Army _ Address DDRW 5har_ e "Lathro _ Phone 20 982-2093 Owner's Name ' License No. LU! 90942 Phone 510 46 —4 00 Contractor TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L) OTHERNK Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK = SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE ,TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS g N A C7 Industria{ ❑ Open Bottom .� .❑ Manteca Dia. of Wall Excavationh ❑ 1(] inch Dia. of Well Casio ` Type of Casing— NSA Specifications ' fa Domestic/Private ❑ Gravel Pack # ❑ Tracy yP bleat cMEnt F Nother I-1 Delta Depth of Grout Seal 0-20 feet Type at Grout I'1 Public B & I I Irrigation .., Approx. Depth t I Eastern Surface Seat Installed by O f Repair Work Done LJ Type of Pump NA . H.P." State Work Done :.—— to I Well Destruction @W'-Well Diameter 6 to 10 inc"1$E�Ing Material & Depth M)} "1 Depth MaX 2.0 feet Filler Material A Depth _Neat cement snout—_ _, f TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR(ADDITION i I DESTRUCTION I I iNo septic system permitted if public sewer is — available within 200 Ieet.I Q L '' installation will serve: Residence_ Commercial Other y Number of living units: Number of bedrooms Character of loll to a depth of 3 feet: Water table depth _J� Capacit No. Compartments l SEPTIC TANK ❑ Type/Mfg y PKG. TREATMENT PET. ❑ Method of Disposal " j, Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ NO.'& Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest. Wall Foundation — Property Line SEEPAGE PITS I I Depth ' Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line " 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 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 applica must c far. req ' in i Complete drawing on reverse side. Signed Title: Project Manager Date: 212193 FOR DE0ARTMFNT USE ONLY ., fe 9 Application Accepted by DateArea -7123" 0. Pit or Grout Inspection by Data� — Final Inspection by Date, F , _ a ,"Additional Comments:' ;I Applicant= Return,all copies to: San Joaquin County Public Health Services ��(� ( ! Environmental Health Permit/Services v 445 N•San Joaquin, P 0 Box 2009, Stkn, CA 95201 t FEE AMOUNT DUE AMOUNT/R�EMITTED CASH IN �y CK 9 R�E'C�EIjV�jEDZBYx DATE PERMIT"NO. I`{ EH'13.24(REV.1/n51 fD w f O O ;e I EH 14.16 �L lI