93-0438 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 I P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 compliance with San Joaquin C unty Ordinance No. 549 d 1862 and the Rules end Regulations of San Joaquin County Public Health Services APY Lot Size/Acreage Job Address er's N ddr - Phon o ctor , is se No. Phone TYPE OF WELL/PUMP: NEW WELJJ WELL REPLACEMEN fl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR, OTHER ❑ Monitoring Well ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE T 4 FOUNDATION AGRI.0 LTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL .. PROBLEM AREA CONSTRUCTION.SPECIFICATIONS C� f /01dustrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ns estic/Private ; ❑ Gravel Pack ❑ Tracy Type of Casing_ Specilic Grouublic [.1 Other n Delta Depth of GroutSeal7y of Grout I I Irrigation —.Approx. Depth i I Ostern t Surface Saul Installed by Repair Work Done 0 Type of Pump H•P�+ — State on 1 Weil Destruction ❑ Well Diameter t Sealing Material & Depth �. �• # Depth Filler Material & Depth ,A 3 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ! I DESTRUCTION I 1 INo septic system permitted if public sawer is avaifable_within_�t]0_Ieet,.M� � Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK. ❑ Type/Mfg Capacity No.gCompamments j PKG. TREATMENT PLT. ❑ 1. r -. f Method of Disposal 1 Distance•to-nearest:• —Well "'-`' Foundation Property Line nA 'Y' `� y LEACHING LINE L❑ No. $ Length of lines Total length/size f FILTER BED 0 Distance to nearest., Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI—Distanceto nearest:.` Well Foundation _ Property Line i f {t DISPOSAL PONDS D " 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 owneror 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 mariner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature --, t certifies the following: "I4rzifythat.r the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of 'foenla." The applic t A calld in coons. Complete drawing on r rse sid 'Sig Titl ec 44 A==4 Date: f R DEPARTMENT USE ONLY c Z70Application Accepted_'by Date `� - Area f Pit or Grout Inspection by Date Final Inspection by ate Additional Comments:." Applicant M 'Retu' n all copies to: San Joaquin County Public Health Services Environmental. Health Permit/Services 445 N San Joaquin, P d Box 2009, Stkn, CA 95201 _.e3 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DAY. PERMIT N0. INFO CASH q . EH13.24(REV.1 K,5) r j EH 14.25 - f_ �