93-0485 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201. PERMIT ESP I RES I YEAR FROM DATE ISSUED j (Complete in Triplicate) Application 1s hereby made; lto San Joaquin County for a Permit to construct and/or install the work herein described. This application is made in cowliance with San Joaquin County Ordinance No. 549 and 1862 and.the Rules and Regulations of Ban 1 Joaquin County Public Health Services. Job Address �~ City Lot Size/Acreage Owner's Name �I-.- kddress Phone ConUact Addressk alk, +-- �inse N ✓'7 �'�` Phene TYPE OF WELL/PUMP: Il NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION 0 Out of Service well ❑ i PUMP,. INSTALLATION SYSTEM REPAIR OTHER 0 Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELt PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA `CONSTRUCTION SPECIFICATIONS 0ial 0 Open Bottom 13 Manteca Dia. of Well Excavation Dia. of Well Casing faZstic/Private ❑ Gavel Pack 0 Tracy Type of Casing_ Specifications I'; Public I.1 Other n Delta t Depth of Grout Seal Type of Grout I I Irrigation �� Approx. Depth I I Eastern J---surface Seal Installed by Q l Repair Work Done . ;Typo of Pump �`� -�R- .H.P. �� - State Work Done Well Destruction ❑ "Wal! piameter. - t ^r Sealing Material i.Depth DePtft �..�% � Filler,Material i Depth _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is `� F .I1. --r I available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: 4 Number of bedrooms ' Character of loll to a depth of�3 feet: Water table depth SEPTIC TANK 0 Type/Mfg ---Capacity---- No. Compartmants PKG, TREATMENT PLT.Cl 1[ -�O.F _ Method of Disposal i Distance to nearest: Well Foundation `'' Property Line LEACHING LINE C1 No. 8 Length of linea 4 Total length/size ,F FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth - ' *• :Size Number SUMPS ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 iI 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 Sari,kJoaquin County Home owner or licensed agent's signature certifies the following: "l certify that in the pert ormance of the work for which this permit is issued, I *hall 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, 1 shall employ persons subject to workman's_ compensa- tion laws of California.,, The applicant must call fa 1.required inspeptions. Complete drawing on verse.side.. _ Signed X� 1F � — Title: ._ Date- y1�2- 93-- FOR 3 FOR DEPARTMENT USE ONLY Application Accepted by Dots Area '2 1- i Pit or Grout Inspection by Date Final Inspection by Date 'V / -f-3 Additional Comments: 11. ii Applicant - Return all copies to: . San Joaquin County Public Health Services �� Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK-CASWRECEIVED BY DATE PERMIT ND. INFO 1� f� E J . EN M24(REV.I i n SI �� 457(TT) ��• �J � �i�.,� 6D � '�+�D EH 14-26 r jM -