91-0093 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT , SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION N �� ' P O BOX 2009, STOCKTON, CA 95201 C� (209) 468-3447 C PERMIT .E%PIRES 1 YEAR FROM DATE ISSUED �,�� (Complete in Triplicate) Application is hereby trtsde,to San Joaquin County for a permit to construct and/or install the work herein described. This application is rmde in coaipliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �,p � bqob Address �'`' ��/G__.!!��- City �� ^ Lot Size/Acreage kY wner's Name P_f��Address � � 1�C-��'- Phane 2 } L 9-2`7 Cantractoi �� E'P'� Address License No. Phone tTYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well i7 DISTANCE TO NEAREST: SEPTIC TANK:- ----SEWER LINES� �� DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL __ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing { U Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public Cl Other 0 Delta Depth of Grout Seal Type of Grout M Irrigation Approx, Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction 10 Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTIONA INo septic system permitted if public sewer is n available within 200 feel.f l - I Installation will serve: Residence_ Commercial— Other .. Number of-living units: Number of.bedrooms Character of soil to a depth of.3 feet: - - - Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. C1 r Method of Disposal Distance to nearest: Well ` Foundation Property Line LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation ` Property Line l SEEPAGE PITS 11 Depth Sire �Number f: f SUMPS Ll Distance to nearest: Well Foundation Property_.Line y. 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, and 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 'I 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 permit is issued, 1 shall employ persons subject to workman's compensa- tlon laws of California." The applicant must for all requir specti ns omplete drawing on reverse side. r aligned X Title: __� 17 _ Date / .57/ DEPARTMENT USE ONLY Application Accepted by Date '1 L l Area I Pit or Grout Inspection by Date Final Inspection by V �PoDate r�.rs Additional Camnnents: • . Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P'O HOS 2009, STOCKTON, CA 95201 INFO EEE MOUNT DUE AMOUNT REMITTED L. CASH RECEIVED BY DATE + PfRM1T'NO. I EH 13.7101EV. 51 ED� ZIP �� ( ! (•EH.1•?e d� Lim