93-0549 - Laserfiche WebLink

Home Browse Search

` APPL I CATI CSN FOR PERMIT ("li 4-rV &55-� � Lf y f . SAN JOAQUIN COUNTY PUBLIC HEALTH- SERV ES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR VRQX DATE ISSUED (Complete in Triplicate) tib• 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 coWliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. e Job Address t O -T�� YV1 �� ' City —J r0 L 2 Lot Size/Acreage r Owner's Name knb� -t �ozz lc Address �lyd 5 3 r I� ?C� Phone `�� Contractor L + Address 100 r f lnF'AMCA Is license No. Phone La 1 a T TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Weil ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well C3 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public f 1 Other ❑ Delta Depth of Grout Seal Type of Grout 0 Irfigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Dona U Type of Pump H.P. State Work Done_ Wait Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION 17 REPAIRlADO1T1 ftA D TIO (No septic system permitted if public sewer is 00) ilable within 200 feet.) 1 ) Installation will serve: Residence�.-, Commercial_ Other q/ 'f Number of living units: Number of bedrooms �E; {, r Character of soil to a depth of 3 feet: _ eF'.tillepth SEPTIC TANK. ❑ Type/Mfg �P $'i Yj a W.i/�t�C�p�mpartments PKG. TREATMENT PLT. C7 dflj ft ` ' �� et�hliid of Disposal Distance to nearest: Well Foundation oK1 ! r 4 4! j LEACHING LINE D No. & Length of lines Total length/size FILTER BED LI Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONOS O I hereby Cartify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following; "I comity 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 persona subject to workman's compensa- tion laws of California." The applicant mv4t call for all required ' spsetions. Complete drawing on rover" a�side. x Signed t 2Title: _ w ,-CP ., ...___--. Dote: F R DEPARTMENT USE ONLY � � 1 Application Accepted by ` Date n `� Area OZ ! K% ` Pit or Grout Inspection by Date Final Inspection by Date Additional Comments. Applicant - Return all Copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 1�v FiE E �� INFO AMOUNT DUE AMOUNT REMITTED [ASH RECEIVED 8Y DATE PERMIT NO. 013- o Y� R