WORK PLANS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHO (209)468-3420 P O BOX 2009, ST CA 95201 PERMIT MIRES 1 YEAR ON D .TE- ISSUIED (Complete in Tr plicate) 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Re Joaquin County Public Health Services.� ,Q Regulations of Sea Job Address Wtr4 Kt4{e-A-at- �t1G —_ City Cod- Lot Size/Acreage Owner's Name Wt if C'crgo S�vLK Address Phone Contractor 1yI I �yC�l{orat'�c`t�f l(�( Address IeARr�i• er9REPLACE Z License No, bgZ�Z:O phone /0 419" 10.4 TYPE OF WELL/PUMP; NEW WELL ❑ WELLENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ AIR ❑ OTHER onn�itoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK >2 SEWER LINES DISPOSAL FLO>teff PROP. LINE >Q'� FOUNDATION >$'e AGRICULTURE WELL rION OTHER WELL-?! PITS/SUMPS 2� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Wetion r+► Dia. of Well Casingn Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Ca � Specifications �A Il Public rot I)k Other &rvr n Delta Depth of Grout Seal NA Type of Grout9A0ArAe-e&- ' I Irrigation ��r App a*.^Ipth I 1 Eastern Surface Seal Installed by r1A S(vrr� Repair Work Done 0 Type of Pump H.P. State Work Done — Well Destruction ❑ Well Diameter Sealing Material 4 Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I i INo septic system permitted it public sewer is available within 200 feet.) 7*� { Installation wile serve: Residence— Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth s"l7' SEPTIC TANK. C3TypelMfq CapenY No. Contde PKG. TREATMENT PLT.❑ Methodpfel Distance to nearest: Well Foundation Property Line Ce D UCT—,79 i LEACHING LINE ❑ No. & Length of lines Total length/s, qSAN ly FILTER BED 13 Distance to nearest: Well FoundationPrr�Y �'ERVICES WTAt 144F a EA TH SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I I hereby certify that I have prepared this application and that the work will be dome n 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: "1 certify that in th 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 compensatior taws of California."Contractor's hiring or subcontracting signature Certifies the following: "I certify that in the performance of the work for which this per rtit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mat call for all required inspections. Complete drawing on reverse sike. Signed x �•e �• /l-r / I Title: u •4 er Date: Af�s ✓rrfKe.cti / Ca.�tJl�-M�r rF R DEPARTMENT USE ONLY ,yJ Application Accepted by Date '� Area Lit✓ rW , I Pit or Grout Inspection by Date Final Inspection by Data y Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services U I Environmental Health Perms /Services �✓• 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 FEE )NFO AMOUNT DUE AMJ�Oj'UUNT,T REMIrtED I CASH RECEIVED BY / GATE PERMIT'NO. • EN II.24 IRS/."S) r V r 1/42-3E r��rLTI 00/-i