91-0505 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT . a SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-344-7,_;V1 ,`0 YEAR (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to eonetruct and/or install the work herein described. This application is made in ccupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations-of Ban Joaquin County Public Health Services. 1�qO �^ Lot Size/Acreage Job Address / J �r Y'�11 City f Address. Phone '30 Owner's Name ChAr ` Contractor ✓ Address License NO. Phone �� TYPE ITOF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well Ll DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation.._ Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑•Tracy Type of Geeing SpecificationsType of Grout M Public I',1 Other ❑Delta Depth of Grout Seal M Irrigation Appro:. Depth ❑ Eastern Surface Seal Instailed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF.SEPTIC WORK; NEW INSTALLATION 0 REPAIR IAODITION DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.l installation will serve: Residence Commercial Other t� Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: star table depth SEPTIC TANK. ❑ Type/Mfg Capacit No. Compartments (� PKG. TREATMENT PLT,0 � f _ Method of Disposal �_ "' �1 Distance to nearest: Well Foundation Property Line -- LEACHING LINE L1 No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property.Line . SEEPAGE PITS 11 Depth Size Number o SUMPS <m Ll Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ I hereby certify that ! have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, andt rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the perlormance of the work for which this perm- is issued;-I shall nolo f California." Contractor's hiring or sub Contracting signature employ any person in such manner as to become subject to workman's compenea_lion laws o I 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 Iowa of California." " The applicant must ca for all r uirad inspecti ns. Complete drawing on reverse side. Signed Title: Date: CI EPARTMENT USE ONLY 3 r Application Accepted by Data res Pit or Grout Inspection by Date Fina Inspection y Date t Additional Comments: — Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O SOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C x RECEIVED BY DATE PERMIT NO. INFO 4 -yy Jr • EH 13.241REV.IIitVli, 3J//_^J` I l V '[.J E4,x [ ..