93-942 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 JP O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) j 9 Application 1■ hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This application is made in ccup1lance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City Lot Size/Acreage v Owner's.Name. _V _.— 4� &'M,'' �_ L Phone r 5 3 '? � R 2 Contraclor Address a License No. hone t TYPE OF ELL/PUMP: NEW WELL ❑ WELL REPIA EMENT n DESTRUCTION Cl Out of Service well ❑ PUMP INSTALLATION ❑ __._.,, .,..SYSTEM REPAIR O OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK,-:L-'Lk- SEWER L'INE_S aw•-- D - SAL FLD. PROP. LINE FOUNDATION `� AGRICULTUFiE,W6 OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONS CTION SPECIFICATIONS Ci Industrial ❑ Open Bottom ❑ Manteca of ell Excavation Dia. of Well Casing n� C1 Domestic/Private ❑ Gravel Pack�k f n Tracy; Type o Casing_ Specifications 1'1 Public Cl Other t !! f 1-Delta Depth I Go Seal Type of Grout V` v I I Irrigation, —.Approx. Depth I IlEaste n Surfac Seal Installed by t Repair Work Done ❑ Type of Pump ''I H.P. State Work Done Well Destruction ❑ Well Diameter t Sealing Material i Depth.-` r Depth f e Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION, REPAIR/.ADDITION-I 1,_DESTRUCTION I I INo septic system permitted if public sewer is r� available within 200 teet.l Installation will serve: R"denco-_IG Commercialthery Number of living units: Number'of bedrooms Character of soil to a depth of 3 feet: 1 _ Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT.❑ ' Method of Di sal Distance to nearest: Well Foundation--SALProperty Line, 04 - \ It LEACHING LINE ❑ No. 5 Length'of lines To et length/size FILTER BED ❑ Distance to rNarest: Well ls1J�_' Foundation Property Line SEEPAGE PITS I I 'Depth 2 Size N 10 n1ber f SUMPS Ll Distance to rw rest: Well Foundation O' Property Line , DISPOSAL PONDS ❑ I /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 lawsi,end rules and regulations of the San Joaquin County 4 Hone 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 t _ employ any person in such manner as to become subject to workman's compensation taws of California."Contractor's hiring or subcontracting 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 Iowa of California." The applicant si call fM=,::��._ Tftlw plete drawing on reverse side. _ •�. signed Data: ... ORD ARTMENT USE ONLY lv� Application Accepted by Date Area 0 �6v Pk or Grout Inspection by Date Final Inspection by Date S ZS p ► e - ,.� 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 t IEEE AM OUNT DUE f AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. j .'EM!724[REY.1ihs) 0 dGL�✓ / _37a Eli t�-2a 11 2 }