SR0001416 - Laserfiche WebLink

Home Browse Search

. Date . Area ENVIRONMENTAL HEALTH DIVISION h°21VZ,0 APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERV I C 445 N SAN JOAQUIN , PHONE ( 209 )468-3420 NOV j 0 1993 P 0 BOX 2009, STOCKTON , CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE I SSUEg\1 PERMIT/SERVICES VIRONMENTAL HEALTH (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 ccailisnce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 161 DC: iJ J. ddraa0 Owner's Name /IVO PailLit15 et.„„H. Address p0 a:iy S13 ll Phone t - )0 C-j-Li)13 Dri lit& ddress PA.,') .1K))( 3-ic. License No. Phone Contractor U G TYPE OF WELL/PUMP: NEW IELL 0 WELL REPLACEMENT El DESTRUCTION Out of Service Well 0 PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 Monitoring Well 0 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 IOW I CI Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation )0/ ti CIO Dia. of Well Casing n Domestic/Private 0 Gravel Pack CI Tracy Type of Casing Specifications I ' I Public [Ti Other Fl Delta Depth of Grout Seal '7.'3 (re Type of Grout atiCti-i- orwo 1 I Irrigation ____ Approx. Depth I I Eastern Surface Seel Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Material 4 Depth , TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) 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 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 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." City S1r..04.177)r\ Lot Size/Acreage The applican call for all req ...AC A / t? dzi) i#9 e 'Aft 1 .• Applicant - Return all copies to: San Joaquin County Public Health Service Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 5 Date SA6b3H 1 55r° Application Accepted by Pit Of Grout Inspection by Additional Comments: Signed inspections. Complete drawing on reverse side. Title: r(16, il FOR DEPARTMENT USE ONLY Date Data Final Inspecti n by //-/313 . EH 13-24 !REV. 11 1151 EH 14-241 FEE INFO AMOUNT DUE AMOUNT REMITTED cra-Sti R CEIVED BY DATE PERMIT NO. .CO ife5 i , #, IHZ-93 COO /&