93-2057 - Laserfiche WebLink

Home Browse Search

APPLICATION SANS',JOAQUINr,COUNTY PUBLIC HEALTH SERVICES ` ENVIRONMENTAL HEALTH DIVISION �= N SAN 45 JOA UIN, PHONE (209)468-3420 4 Q P O BOX 2009, STOCKTON, CA 95201 si PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,I (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 cemipliance vith Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. - 1w1'�r - 1,-,OF 41 Job Adf. dress ant City c�Lot Size/Acreage Q Owner's Name �"^�� ' Address Phone s lliislt - thlJ l Z$, i E.M filer O E Contractor Address License No. 51LLtfJV- __Phone - i TYPE OFoWELL/PUtMP: i NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ f PUMP INSTALLATION ❑ SYSTEM R�EP�AIR 17 OTHER V Monitoring Well [3K j DISTANCE TO NEAREST: SEPTIC TANSEWER LINES �i.tl.l___ DISPOSAL FLD.N_ PROP. LINE '- t FOUNDATION 7 r AGRICULTURE WELL<_L11i It OTHER WELLS PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4Itntile (715or) L7 industrial O Open Bottom ❑ Manteca Dia. of Egxcavattiiro�tn _ LO Dia. of Well Casing ' C] OomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing_— Specifications-. - — f ``ttnn I Other P Delta Depth of Grout Seal Allam _ Type of Grout NA I"i Public 1 I i Irrigation ,1Qr Apprax. Depth I�Eastern(SJLtWrt Surface Seal Installed by NA Repair Work Done v Type of Pump NAA H.P. NH — State Work Done _ Well Destruction ❑ Well'Diameter �►aA Sealing Material & Depth NA Depth Filler Material & Depth TYPE Of SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDiTION I i DESTRUCTION I 1 INo septic system permitted it public sewer is available within 200 feet.) Installation Will serve: Residence— Commercial _ Other Number of living units: Number of bedrooms i. Character of-soil to a depth of 3 feet: t Water table depth, 4 ] SEPTIC TANK. D Type/Mfg 'Capacity No. Compartments' PKG. TREATMENT PLT.❑ i„�. ,� t:t• _ i �� Method of Disposal Distance to nearest: Well Foundation Property Line k LEACHING LINE ❑ _No. &Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t _ 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 agerkt'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 minner as to become subject to work man'i.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, t shall employ persons subject to workman's compensa- tion laws of California." ' The applicant ,,muusst-ccallll,ffor all r e quired insPections. Complete drawinglon reveise side. Signed X.� r t�vl Y AGF-�// Title: Date: A193 FOR DEPARTMENT USE ONLY x.1% s = q ARPlicatign Accepted by, Date Area Pit or Grout Inspection bDate)0 7 Final Inspection by Data 4f� Additional Comments: � r 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 (JJ FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. I+NFBBn /� /� EK 13.24 1REv.t/H 5)V V /� - X 7 '✓ 35f1w_\ '10 a ID-dO 15 7 EH 74.26 - C.J U [�"'-� - ((