93-0119 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRCKMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 ,P 0 BOX 2009, STOCKTON, CA 95201 C 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 in made in compliance vith San Joaquin County,Ordinance .No. 549 and 1862 and the Rules and Regulations of San j Joaquin County Public Health Services. I Job Address City _"'cel/ Lot Size/Acreage `^ p{ 31✓ �r�VY 7 Owner's Name ��^A�� ="�'��- Address ' r' "�-- Phons Contractor Addresses License No.t�JL%5;W Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Well �1 -PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ lAonitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS C] Industrial ❑ Open Bottom ❑ Manteca +Dia. of Well Excavation Dia, of Well Casing [1 Domestic/Private ❑ Gravel Pack ❑ Tracy TypsaLC S cilica�WMI��V ;y I'] Public �r EI Other. n Delta .^DepthAoiI ro ��I$�O Uu I I Irrigation !Approx. Depth I I Eastern .1 Surface Soul 5stal e �1 Repair Work Done U Type of Pump H:P. IIV& Dor D 7►li TT-- - _- \\` I Well Destruction ❑ Well Diameter Sea a material DeirtS Depth Fil Iyaterial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION IAF- DESTRUCTION I I iNo septic system permitted it public'6ewer is :j f �. ' available within 200 feet.) 1-01 1 Installation will serve: Residence' A-- Commercial-— Other Number of living units: umber of bedrooms. - Character of moil to a -� - Water table depth depth of 3 feet: _.. � ��1-�-�"`--- SEPTIC TANK. ❑ Type/Mfg r Capacity No. Compartments - i PKG. TREATMENT PLT.❑ Method of Disposal i Distance to nearest: Well - "Foundation Property Line } LEACHING LINE Cl No. 6 LengtOdf line - -;10-L-- ---. Total length/size` O � FILTER BED O Distance to`rr5sarest: Well es i Foundation f Property Lins 5- 1 SEEPAGE PITS iti-Depth c2=5 1 Size Number SUMPS Ll Distance to dearest:: Well 0 f Foundation0 1 - Pr I r - ---- Property Line - FDISPOSAL PONDS ❑ f2. I hereby certify that I have prepared this application and that the work will bs done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County r . Home owner or licensed agent's signature certifies-the 4oll6wing: "1 certify that in the performance of the work for which this permit is issued,-d shall not employ any person in such manneras to become subject.to•workman's compensation laws of Calif ornis." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the perfor mance'of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion Iww of California." The applies II f all requirgoinsp$66ne. Complete drawing on reverse side. Signed X ��. ? - _ - __ Title: Ci�GVA C 6j �� Date: : � f R, EPARTMENT`USE ONLY Application Accepted-bye A116 Date1"~d -Q:!� Area � Z or Grout Inspection by inlel� ¢-.Date 2- Final Inspection by Data A. 7Z I- Additional Comments: w Applicant - Return-all copiesjto: Sali,Joaquin County Public Health Services .n Environmental Health Permit/Services 1` 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 IFEENFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY GATE PFM17. • FM 13'24 1{-24IIIEV.tIA5i ' �, °� 1/