93-0539 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ,f 445 N SAN JOAQUIN, PHONE (209)468-3420 P, O BOX 2009, STOCSTON, CA '95201 -7 PFMIT EXPIRES `1 YEAR FROM DATE (Complete in Triplicate) - y Application is hereby made to San Joaquin County for a permit to construct and/or inatall the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San' Joaquin County Public Health Services. 1173 6-2. 1 Lot Size/Acreage Job Address '° � City �r _ - T,Qd - Owner's Name 'Mals_ on-Ritzman ' Address PO Box 836 Woodbridge Phone 369=9130 Contractor C 11'a r k We 11 I n c - Address 2 0 2 4 E. Ch a r te r License No. 3 7 1 5-6`0- --Phone 4 TYPE OF WELL/,PUMP: NEW WELL WELL REPLACEMENT' ..,--.DESTRUCTION ❑ Out of service Nell ❑ " II PUMP INSTALLATION SYSTEM REPAIR El OTHER ❑ Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES DISPOSAL FLO. PROP. LINE Il FOUNDATIONT AGRICULTURE WELL OTHER WELLS PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1r " C7Yindustrial I; g Q pen Bottom ❑ Manteca Dia. of Well Excavation -�— Dia. of Well Casing r U x<�Domestic/Private 0 Gravel Pack n Tracy Type of Casinji'it. Specifications 11 Public 'n Other n Delta Depth of Grout Seal ' Typo of Gro 1;L, tis -. XJ)t Irrigation. Approx. Depth I I Eastern Surface Seal Installed by y I: Repair Work Done U Type of Pump H.P. State work Done _ Wall Destruction ❑ Well Diameter' Sealing IMterialbi Depth r Depth Piller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 leetJ w• Installation will serve: Residence Commercial— Other / Number of living units: Number of bedrooms Character of toll to a depth of 3 feet; i Water table depth SEPTIC TANK I1 ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance_to rmearest: Well Foundation _Property Line -- ,.. LEACHING LINE ❑ No. & Length of lines_ Total lengthtsize FILTER BED i ❑ Distance to nearest: Well Foundation Property Line 9 SEEPAGE PITS z i l Depth + -Silo Number SUMPS I[ - L1 Distance to nearest: Well Foundation Property Line :ah 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 end regulations of the San Joaquin County Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any petson in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: "I cert'-_4 4W t rfor7CCcftnpleto a of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif m The epplica t II drawing on reverse side. i Signed Title: VP Clark Wel.l . 'Inc Dete: 5 April Y 93, OR DEPARTMENT USE ONLY r 4 C2� Application Accepted by - Dose _ Area_.... --- I Pit orr inspect n,b mate Final Inspection by Date" u Additional Comrn*n B Applicant - Return all copies to: San Joaquin County Public Health Services �i Environmental Health Permit/Services ji 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 \ FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ` i INFO F �y(� �] .,EM13,24(REV,1/015)01�'i ( �?� f ` L:> �3�`� EM 14.20 II � �