93-0828 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-8420 P 0 BOX 2009, STOCKTON, CA 95201 PERMITEXPIR_ES 1 YEAR FRQM_DATE_ I$SUED (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 cat)llance with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. / Job Address of�7J � 7 Z LG! / `e L City ffd_kAr�7_ Lot Size/Acreage !2/`f cll c lei__ Owner's Name "F;// 7— Address Phone Contractor Address �fUo � �n d2 f* License No. Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing N Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications p , I'1 Public 1_1 Other fl Delta Depth of Grout Seal Type of Grout ]�3 I I Irrigation —.Approx. Depth I I Eastern Surface Seal installed by Repair Work Done U Type of Pump H.P. State Work Dane_ Well Destruction ❑ Wall Diameter Sealing Material A Depth Depth Filler Material i Depth y TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I iNo septic system permitted if public sewer is v available within 200 leeLl Installation will serve: Residence. _ Commercial— Other Number of living units: Number of bedrooms. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK (a Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ r Method of Disposal Distance to nearest: Well 20" Foundation 7 Property Line LEACHING LINE M No. & Length of line Total length/size � FILTER BED 0 Distance to nearest: Well O r Foundation /JProperty Line SEEPAGE PITS K Depth aad�2 Size I&L`` `f Number SUMPS LI Distance to nearest: Well Foundation;D7 Property Line C� 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 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 parson 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 laws of California." The spplic at call for r uired inspections. Complete drawing on rever side. r - � /— Signed Title: _ Vic--.___ Date: qr ~�f Ap �0FOR DEPARTMENT DISE ONLYApplication Accepted by 1 la4�� _ Data Area Ph or Grout Inspection by Date Final Inspection by Date AW—43 ._r 4.3 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 INFO FEE AMOUNT DUE AMOUNT REMITTED CK CASH wHRECEIVED BY DATE PERMiT'NO.y�{^ . EH 13-24 ) N V.r,eei ,� �f , °= do7 Io ogpgr/ EM 11.26 1 1 V