93-1207 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 f � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �'`��"' J (Complete in Triplicate) Nth � � , x 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. X Job Address ' S }�. City G OO Lot Size/Acreage Y, Owner's Name UldAddress ( 7 '►/ �f L� e-�- f�_ Phone VZ / u Contractor Address License No, Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i F.l Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing_ Specifications I'I Public Cl Other f-1 Delta Depth of Grout Seal Type of Grout \ I i Irrigation —Approx. Depth I I Eastern Surface Seal Installed dy i Repair Work Done 0 Type of Pump H.P. —_ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth ,I Depth Filler Material & Depth I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIO o septic system permitted if public sewer is available within 200 feet.I Installati ill serve: Residence_ Commercial_ Other Number of living u '`�`` Number of bedrooms Character of coil to a depth ��f t: r labia depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT:❑ Method of Disposal Distance to nearest: Well stion Property Line r I LEACHING LINE ❑ No. & Length of lines Total Is ize L FILTER BED n Distance to n Well Foundation Property L+ SEEPAGE PITS epth Size Number ' SUMPS LI Distance to nearest: Well Foundation Property Line s DISP PONDS ❑ I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and i 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." T e applicant mus call for all r uired in`sti s: Com a drawing on reverse side. 1 Si ned �� C / Title: _ ,� - r g - C_� _±`._L Date: -- FO TMENT USE ONLY Application Accepted by Date .a+c. L Areay 1y KM Pit or Grout Inspection by Date Final Inspection by Date C1 _,,� �j I Additional Comments: _� - t,0,1-5Cf °,1`s A Pct' 912'x9S care. Cdk�Glt� ever �d+n j Applicant - Return all copies to: San Joaquin County Public Health Services `��,Vn` Environmental Health Permit/Services F°�� G 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 �I+FEE AMOUNT DUE AAM�OUN REMITTED CK CEIVED BY `} DATE PERMIT'NO. . EH19-24(REV.t r M Sr SIa ! �D jbDn (� �• EH U•2a !!1 „'