91-0958 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O SOS 2009, STOCKTON, CA 95201 (209) 468--3447 Y R (Complete in Triplicate) Application is hereby raade,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 ,1862 and the Rules and Regulations of San f Joaquin County Public Health Services. Job Address City Lot Size/Acreage Owner's Name ,�-a�z p 'Su ik1 � Address ��3 � 6-10 k, Phone Conlractor 1 I >' Address PD. License Noc9gg1.3d= Phone-3&S'-)7-7 TYPE OF WELL/PUMP: NEW WELL" WELL REPLACEMENT° DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION W SYSTEM REPAIR ❑ OTHER 0 Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE.�c-rte FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fr F_1 Industrial XOpen Bottom ❑ Manteca Dia.of'Well Excavation Dia. of Well Casing Domestic I Private ❑ Gravel Pack n Tracy Type of Casing:!Mee-I_-_ Specifications p Public I:1 Other O Delta Depth of Grout Seal ` Type f Grout Cl Irrigation +��,Approx. Depth d Eastern Surface Seal Installed by Repair Work Done�U_Type of Pump w H,p,�' _ State Work Done _ Well Destruction 0 Well Diameter Sealing i/aterial fi Depth "� � � � 1pw s Depth Filler Material A Depth y TYPE OF SEPTIC WORK:, NEW INSTALLATION Cl REPAIRIADDITION M DESTRUCTION 0 (No Septic-system permitted if public sewer is 1 a available within 200 foot.) to r lnstallation will serve: Rea tl nce--__. Commercial T, Other Y S Number of living units: N Nu hmerof bedrooms k Character of soil to a depth of 3 feet. � �' - Water table depth SEPTIC TANK /p�Typi/MfgCapacity No. Compartments PKG. TREATMENT PLT. Cl �. Method of Disposal {j Distance to nearest: Well Foundation. Property Lina Y LEACHING LINE ❑ No. & Length of lines Total lengthysixe FILTER BED ❑. Distance-to nearest: Well Foundation Propeny•Line SEEPAGE PITS I I Depth , v" Size Number SUMPS LI Distance#to nearest: Well Foundation Property Line 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 taws, and rules and regulations of the San Joaquin County S Home owner or licensed agent'raignature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall not i employ any person in such manner es to.become subject to workman's compensation laws of California." Contractor's hiring or,sub-contracting signature j 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 call for all required inspections. Complete drawing on reverse side. l { Signed Title: 5 Date: d a F EPA ENT USE ONLY Applicaliqn Accepted b Date �a Z Area Pit o Grout I spaction Final Inspection b �_ pat fci--ck l Additional Comments:Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2005, STOCKTON. CA 85201 FEE AMOUNT DUE AMOUNT REMITTED CK RECFIVEO 8Y DATE_._,.Y_ Eoi r INFO, - - — -- .—CASH--_ .-.� _ - . EH 13.24 IREY.iN sf ^