93-0996 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION X445 N SAN JOAQUIN, PHONE (209)46$-3420 . P 0 BOX 2009, STOC%TON, CA 95201 iPERMIT EXPIRES 1 YEAR FROM DATE ISSUED - (C omp 16 t,e-.-i n. SSUED -(Comp.16t'e__..in.Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the Work herein described. This application in made in complianZ with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulatione of San Joaquin County Public Health Services. Lot Size/Acreage Job Address �fd 1 Z7� (� ��V AY� City e� Owner's Name A EILIE-"::V y/4rL-Address Phone j. ContractAddress j rmLicense fVo2�&_V_Phone TYPE OF WEMPUMP NEW WELL ❑ WELL REPLACEMENT i-T DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ Monitoring well 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 CONS'RUCTION SPECIFICATIONS * Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing * Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I') Ptlbtic Cl Other 1 f l Delta Depth of Grout Seal Type of Grout I i Irrigation _,Approx,,0epth I I Eastern Surface Seal Installed by Repair Work Done L] T ;p p Type of Pum H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material to Depth Depth Filler Materiae S Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence 4 Commercial,_._. Other Number of living units: _L__ Number of bedrooms ______ f Character of soil to a depth of 3 feet: fl Water table depth SEPTIC TANK type/Mfg 1 — Capacity 921CZ2 No. Compartments PKG. TREATMENT PLT. ❑ # Method of Disposal Distance to nearest: Well t27C Foundation -1-0 Property Line_ f �. LEACHING LINE 'V1--4 No. & Length of lines Total length/size It .. � � FILTER BED ❑ Distance toneirf rest: Well�' Foundation 2421 Property Line SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance id nearest: Well Foundation Property Line DISPOSAL PONDS O f 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 1 County Home owner or licensed agent's signature certifies the following: "t certify that in the performance of the work for which this permit is issued, I shall not employ any person in such spanner as to'tiecome 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 applican u for.ell reqed in pections, Com is drawing on reverse side. Signed (( ,� Date: ��"� Title: EPARTMENT USE ONLY Application Accepted by i Date �— d r Pit or Grout inspection by Date Final Inspection by Data c. Additional Comments: Applicant - Return all copies to: San Joaquin County P lic Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH REC�EIVJE'DD BY ' DATE A PERMIT'ND, . EH 13-24IREV.1/H5� l L�� ,_ t t� oL;.i (� ( � 193-OWLEH 14.70 - ��J_� t