92-3085 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 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_ 9MIRES 1 YEAR FROM DATE ISSUED 4 (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 1 made in ccMliance with San Joaquin County Ordinance No. 549 and 1,$(2 and the Rules and Regulations of San Joaquin Coua lie H alth nrllaefl(�AUK& ces. Job Address � rCity, Lot Size/Acreage Owner's Name lJ� Address Phone a - I�Id res * C License No. I Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTf❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ - r 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 LII ustrial ❑ Open Bottom ❑ Manteca_ Dia. of Welt Excavation Dia. of Well Casing omestie/Privam ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications + i'1 Publie 177 Other Fl Delta Depth of Grout Seal Typs,of Grout ' t I Irrigation —.Approx. Depth I I asternSu►isce Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work p Well Destruction ❑ Well Diameter Sealing Naterial i Depth Depth biller Nsterial i Depth w TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDiT1ON I I DESTRUCTION I I INo septic system permitted if public sewer is I - available within 200 feet.) Installation will serve: Residence— Commercial -- Other Number of living units: Number of bedrooms t + Character of soli to a depth of 3 fret: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 4 PKG. TREATMENT PLTXI, Method of Disposal p Distance to-nearest: Well t Foundation Property Line ^ i LEACHING LINE 0 No. & Length of lines ' t Total length/size FILTER BED ❑—Distance -nearest:...,.�Wallz Foundation Property Lina - ' SEEPAGE PITS 11 Depth + Size Number SUMPS LI Distance to neareaV! Well Foundation Property Lina j 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, ander 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 ampiay any parson in such manner as to become subject to workman's compensation laws of California 'Contrector's_hirinp or subcontracting,tsignature_ certifies the folbwinq:,"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 Cal' nis:;' The appllca � t call fo ill r in tions. Complete drawing o4rever ide. Sp Title: Date: V FOR DEPARTMENT USE ONLY Application Accepted by . �SFXAAPOQS4.nn Data - ft-129L Area Pit or Grout Inspection by Date Final In by gOL/IData ALOZ Additional Comrnents: Applicant - Return all copies to: San Joaquin County Public Health Services Ne,�,(y� Environmental Health Permit/Services N` 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EN 13.24 IREV.i i n sY �y.� IN 14-2e � �V V I +� ��