93-0104 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION NO W 445 N SAN JOAQUIN, PHONE (2O9)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 ; N© gtzr r PERMIT E$PIRTS 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 1962 and the Rules and Regulations of Ban Joaquin County Public Health Seraricea. fr Job Address _! 1 2!b �Id '{�'7'1/'�� City I mot Size/Acreage Owner's Name Address '72Phone 4 Contractor ,� r Address �� ' License No,7_ ' )'+? Phone TYPE OF WELL/PUMP:_ „ --_NEW WELL ❑- WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ \ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ -" OTHER 0 Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 161SPOSAL FLD. PROP. LINE p ` FOUNDATION AGRICULTURE 4ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA.. CON TCI SPECIFICATIONS Cl Industrial ❑ Open Bottom CIManteca Dia. Well Excavation Dia. of Well Casing f:l Domestic/Private O Gravel Pack ❑ Tracy of Casing_ Specifications I'I Public 1:1 Other —n Della De 'h"of-Grout'Sial - Type of Grout I I Irrigation —.Approx. Depth I I Eastern Su ace Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Piller Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (Noplic system permitted if public sewer is :- .. avails le hin 200 feet.) Installation w81 serve: Residence Commercial— th r ` Number of living units: Number of bedrooms ��C Character of soil to a depth of 3 feet: Water table depth t SEPTIC TANK j © Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.Cl .— Method of Disposal 1 Distsnce to nearest: Well Foundation Property Line LEACHING LINE CI No. 6 Length of lines Total length/size FILTER BED © Distance to nearest: Well V Foundation Progeny Giia�"—"" SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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, stats laws, and 1 rules and regulations of the Sen Joaquin County ' t__ Home owner or licensed agent's signature oenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not a employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature eenifies the following: "1 certify that in the performance of the work for whiff h this pe►mit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicany{nu st call lor.. uired-i apaClions.Complete-drawing-on-reverse-side. - - Signed ! ,(.e- Title' —---�� tZ .. ., .,_. Date' '- F DEPARTMENT USE ONLY 11 11 ` Application Accepted byAData- L Area _ d L Pit or Grout Inspection by Date Final Inspection by �' Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Hox-2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY )DATE PERMIT NN/O • EH 1121 INEv.ii%51 ` / �� / Q` EH 14-M v Y_,-VD L !