93-0385 - Laserfiche WebLink

Home Browse Search

,A APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 h P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE isppgp (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 coniiliance with San Jon County Ordinance No. 51+9 and 1912 and the Rules and Regulations of San Joaquin County Public Health Services. 1 Q C4Alp Job Address Cit 3 6 Lot Size/Acreage r � Owner's Nam[e'�p I Address Phone Contractor License No. Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT rl DESTRUCTION D Out of Service Well O PUMPISTALLATION ❑ SYSTEM REPAIR 0 OTHER O Monitoring Well C] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L) Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I Il Public Cl Other fl Delta Depth of Grout Seal Type of Grout + I Irrigation —.Approx. Depth 14 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done 'r Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 13 DESTRUCTION l I INo septic system-permitted if public sewer is p available within 200 feei.l Installation will serve: Residence-I-- Commercial— Other Number of living units: Number of bedrooms ( r Character of soil to a depth of 3 feat:_ Q __ _,._.— { Water table depth �f SEPTIC TANK ❑ Typs/Mfg Capacity €, No. Compartments PKG. TREATMENT PLT.O �' Metbod of I s5—S—,��'�£ Distance to nearest: well Foundation Property Line LEACHING LINE dl No. b Length of linea s Ro Total length/size +>�a FILTER BED 0 Distance to nearest. Well Foundation - -- ,Property Line SEEPAGE PITS I I Depth I Size . Nr bar SUMPS s f � Distance to nearest: --'well Foundation ..Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 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, I shall employ persons subject to workman's compensa- tion laws of California." ; The applicant must call for D" equired insrtnyoomplele drawing on verse side. �n SignedtrN, Title: .jLt Data: _ L FOR DEPARTMENT USE ONLY -- Application Accepted by a DateV7 `.Z, ] ��. .. Area Pit or Grout inspection by Data Final Inspection by w Data 3 r� Additional Comments: `v Applicant-- Return,all copies to: San Joaquin County Public Health Services Cr .rt _:;:Znxironment&1 Health Permit/Services 445X'!4sn Joaquin,..P 0 Box 2009, Stkn,. CA 95201 INFOIE' c AMOUNT DUE " l AMOUNT REMITTED C SH s RECEIVED BY DATE PERMIT NO. � 3 � . EH l3-21(REV.sir � ?/� O EH 14-26