93-0664 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION F_ .S � JOAQUIN, PHONE 445 PN0 BOX 2009, STOCKTON, CA,95201 20 ECANNE0 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) L.%1.;,, Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. Thisloi l application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1852 and the Rules and Regulations of San Joaquin County Public Health Services. XJob Address , 30-34 ��v `� � �"� City �� Lot Size/Acreage Owner's Namerfft Q,� -Sqr,G.'r 11 i Address JO, CeIX Phone r � P ° �i onlractpr,��C-�L l�G2YP�7�s� __F+ddres / � License No. Z- Phone KCzr TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REP ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER ES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUR L OTHER WELL PITS/SUMPS _._ INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUC ECIFICATIONS n Industrial ❑ Open Bottom ❑ Mani Dia. of Well Excavation Dia. of Well Casing ,} [l Domestic/Private ❑ Gravel Pack 0 cy Type of Casing_ Specifications I'1 Public 1-1 Other Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. epth I 1 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. _ _ State Work Done, Q1 Well Destruction ❑ Well Diameter Sealing Material i Depth V Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is itable within 200 feet.! Installation will serve: Residence_ Commercial_ Other / �y 2- Number Number of living 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. Distanceto nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number v SUMPS LI 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 lows of California." The applicant us call for al squired inspections. Complete drawing on reverse ide. Signed Title: .� Date: FOR DEPARTMENT USE ONLY r� Application Accepted by L.� Date ,,.`_e)-13� J Area Pit or Grout Inspection by Dat® Final Inspection by Date r Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT'NO. H n n . EH13-?4{AEY.1/aSi Cf� / / � y�� 2 `73 EH t�.1s `�-.T�JJ f 1 7 ✓