93-1070 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sa 'Joaquin County for a permit to construct and/or install the Work herein a lication is made in cndRe described. This f os , rmtth Se a ces. Sea Joaquin County Ordinance No. 5i+4 and 1862 and the Rules and Regulations of San Joaquiri•'rrounty Public Health Se//rvices. .S� !4 r v� ' I, 'Job Address,___. N. Sp - City a C O h Lot Size/Acreage y Owner's Name�� s !r LL4Z nlzAddress �S.Z ctr! r/-r- Phone %O Contractor S Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (-1 DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well DISTANCE TO.NEAFtESTi-5EP71C TANIK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` n Industfiai. ❑ Open Bottom L7 Manteca Dia. of Well Excavation t r'! Dia. of Well Casing HCl Domestic/Private ❑ Gravel Pack ❑ Ttacyr --,-_�4 Typa of-Casing --- - - __ - Specifications- I I Public _ t.l Oilier Depth of Grout Seal r f ' Ll Delta Type of Grout j pprox. Depth I I Easte n Surface Seal installed by Repair Work Done 0, Type of Pumpk H.p, '` > State Work Done Well Destruction ❑ Well Diameter i Sealing Material 6 Depth�-, ' Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR IADDITION I 1 DESTRUCT--- ION,11CIJilo septic system permitted if pubic sewei is r r fi Installation will serve: Residence available within 200 feet.) I Other Number of living units: Numb lk Character of soil to a depth of 3 feet: Water table depf-t t I fi :r t SEPTIC TANK ❑ Type/Mfg p"Capacity No. Compartments i` PKG. TREATMENT PLT. ❑ �� It� ! 7 ' Ou� ` �r ��.�j �d•�!!th Method of Disposal 1f' Distance to nee _ *I `t��ff 1Property Line <. a e �{ ' LEACHING LINE ❑' No. & Lengines h of lines _.rj =°.rNO k Vi ici^+Total length/site j 1 t7 i FILTER BED -X—;C. -""4p�T Distance toi{{nearest; Weppll� Foundation Property Line SEEPAGE PIS ftR`I.I Depth Site{ Number �I ; SUMPS r Ll Distance to nearest: Well' Foundation Property Line t, i tr DISPOSAL P NDS"_""❑. ---' 3y. 4 --- --' _ ►_.� ,r 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 signattire 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." f ' The app" ust ca for all requir 'nspections. Complete dravying on reverse side. j i r1 � � tti Signed Title: w�'I`e r �" 0 Date: FOR DEPARTMENT USE ONLY Application Accepted by �_ Date_ „•�__- Area Pit or Grout Inspection DateI Final Inspection by Date s Additional Comments: Applicant - Return all copies to: "San Joaquin County Public Health. Services t + h � Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 # FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH EH i3-74fREv.t/h5 i 7y t�� O B ; FH 1..� 7. - .� Y 6 r �-g3 .�la~��