WORK PLANS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �. ENVIRONMENTAL HEALTH DIVISION v� 445 N SAN JOAQUIN, PHONE (209)468-3420 �1 1 P 0 BOX 2009, STOCKTON, CA 95201. PERMIT EXPIRES 1 YEAR ROM DATE I SU (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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. '! JobAddreas Z14`; W. ��"t�tMr•h L:.ne �. City La r Lot Size/Acreage Owner's Name ��+�r}M} nL. AddresJs� j5 2 Lj Ind/. Th d J F• I I—, GA 13 2-3o Phone &''1 J e2-' ?Z-41 r� 31,41 r 17LhLrAl �JR. SJt FL L r i7 S AddR,. Conlrar:tor ! �fn41 G� °�"` 'o+� -Address ^�1.. %•r^.,l.v` C� " �rZ License No. E62��•' Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE ENT n DESTRUCTION &4 Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wail Casing Fl Domestic/Private Cl Gravel Pack El Tracy Type of Casi g._ Specifications !'I Public Cl Other fl Delta Depth of Grout Seat Type of Grout I I Irrigation —Approx. Depth I I Eastern Surlace Seal Installed by Repair Work Done U -TypIPohRuxttp u1n -20 04w'ZS H,P. State Work pone _ Depth l i De i t M li eang Material N4.t f,^.�Artx WellDestrusSion Q3 Well Diameter S �� 5"%2 6-s.1.•:. ;f-< :�-. t-; . + tris Filler Material i pth AA1'I" Hru-:L! j A fuu.45' Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION l I !No septic system permitted if publiC sewer is available within 200 feet) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms _ Character of coil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capa ity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that l 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 Sen Joaquin County Horne owner or licensed agent's signature certifies the following: "! certify that in The performance of the work for which this permit is issued, l $half 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 per it is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed � // // Title: 4-° `cf " Date: FOR DEPARTMENT USE ONLY / Application Accepted by 'w Date f I O v Area ' �1 �' (7o Pit or Grout Inspection by Date Final Inspection by Dat* Additional Comments: Applicant - Return all copies to: San Joaquin County Public lealth Services Environmental4ldalth Permit/Services r' 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 J �i FEE AMOUNT DVE AMOUNT REMITTEp CK RECEIVED BY DATE PERMITNO. WWWWWW INFO CASH O EH 3-24 IREV. Df `�- j e 1.