93-0335 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County public Health Services. Job Address, © � � ! �""2 L_ 2 Cit Lot Size/Acreage Owner's Name Address -'�1 _ Phone ta' � Conlrac r�'t Address 'License N Zo Phone �a-��0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring well C.1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing [7 Domestic/Private ❑ Gravel Pack El Tracy Type of Casing_ Specifications I'} Public El Other n Delta Depth of Grout Seal Type of Grout I i Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L1 Type of Pump H.P. State Work Done— Well Destruction ❑ Well Diameter Sealing Material ]Depth - C Depth )ler Materia1fi Depth. I` TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR[ADDITION+ DESTRUCTION I i iNo septic system permitted if public sewer is �� l available within 290 feet.) Q} Installation will serve: Residence l Commercial hev1_— Number of living units: Number of e. rooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ T ype/Mig Capacity No. Compai•tment3 PKG. TREATMENT PLT. ❑r' x Method of Disposal • y. f Distance to nearest: Well Foundation Property Line a , LEACHING LINE_ �.• No. & Length of lines Total.Iangth/size If FILTER-BED • r ❑ Distance to nearest: Well r Foundation Property L(61 t • - /r J I SEEPAGE PITS Depth Sire Number r BLIMPS LI Distance to nearest: WellT® /t r Foundation I�r Property Line s 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 r rules and regulations of the San Joaquin 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 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 app t must call f r req ed inspections. Complete drawing on reversesi g Signed X Title: Vr R Date: FOR DEPARTMENT USE ONLY 9 Application Accepted byLgF - - Date � y 7 Area tutor Grout Inspection byy -' //d � te / '�- Final Inspection by G ata7 � Additional Comments: _ y iI d' /2"<---dYL � --- Applicant - Return all copies to: San Joaquin County public Health Services Environmental Health Permit/Services 445 N San Joaquin, p O Sox 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY GATE PERMIT NO. INFO CASH01 . EH 13-24(REV. a1 b a z EM 14,26 l t