90-2936 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 (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 couoopliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules sud Regulations of Ban Jo%quin County Public Health Services. Job Address .. i_1 dA=V_Z J� A 6_� _ City Lot Size/Acreage Q Owner's Name - DOf2..: f Address Phone Contractor Address License No.� 7F1ES Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well C7 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 n Industrial ❑ Open Bottom ❑ Manteca Die, of Well Excavation Dia. of Weil Casing U Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications M Public Cl Other C] Delta Depth of Grout Seal. Type of Grout CI Irrigation _..Approx. Depth C1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth " TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION CI DESTRUCTIONX--(N o septic system permitted if public sewer is Ilk available within 200 lest.) Ir 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, 0 Method of Disposal Distance to nearest. Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wolf Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS Ll Distance to nearest: Well Foundation ` Property Line 1 DISPOSAL PONOS ❑ 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 cenifies the following: "I certify that in the.periormance of the work for which this permit is issued)shsll,not- employ any person in such manner as to become subject to workman's compensation liws of California." Contractor's hiring of sub-contracting signature # 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 laws of California." The applicant must call for all squired in ctions. Complete drawing on reverse side. Signed XTitle: Date: F DEPARTMENT USE ONLY Application Accepted by - Date 4- S- b Area Pit or Grout Inspection by Date Final Inspection by Date�) Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 95201 INfO AMOUNT DUE AMOUNT RECASH RECEIVED By DATE PPEERMIT'NO.. . EH I3-24IREV.iinSY [/ V �� tLA�— I I r f0 ),9 EH 14.25 c O [