93-938 - Laserfiche WebLink

Home Browse Search

„rev yJ f a APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONN[ENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR_FRg1M DATE ISSUED (Complete in Triplicate) Application is hereby made to Sam 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. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Puh�cVgaly Oervices. vv�t ((�Q[C��CCJJ/' Job Address ._.. ...,,.,..., ,._ '� Q`la .UDI ! ��- City C a Lot Size/Acreage (7f • c r �s H Owner's Name Address ). n Phone Uf- Contractor a”- sy-, Address ?r22t 6Ctf License No. 2 !2-5,,.. Phone TYPE OF WELL/PUMP: NEW WELL)k WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTAL I ATiON O SYSTEM REPAIR ❑ THE ❑ Monitoring Well n DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI.Qw n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack racy Type of Casing, fl _- _ Specifications �_ `i��`�' "1 Public /Other it 1Delta Depth of Grout Seal ,4&:Rl Type of Grout I I Irrigation -0/6_ �pprox. Depth I I Eastern Surface Seal Installed by. ..0461:121t, Repair Work Done L3 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Tiller Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_z-Other Number of Ihring units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal } Distance to nearest: Well Foundation Property Line •r LEACHING LINE 0 No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line r � SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the w k will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County m Hoe owner or licensed agent's signature canifies the following: "I rtify that in the performance of the work for which this permit is issued. I shall not employ any parson in such manner as to become subject to workman s compensation laws of California." Contractor's hiring or subcontracting 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 applican at ca for all Inspections. Com eta drawing on revs _sidle. Signed Title: — / Date: �FDE�PARTM�.ENNT USE ONLY �} Applic Wnn Accepted by f Data � tea �� - Pit or ut '� tion by Date 3 Final Inspection by Date V Additional Comments: - Applicant - Ret n all copies to: San Joaquin County Public Health Services X O �iy Environmental Health Permit/Services U 445 H San Joaquin, P O Box 2009, Stkn, CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DA�(TE,Q PERMIT•NO. . EH13•34IRGv.iinsY 4,p1 V �-1 l EH 14-35t72.12- 5