91-1593 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT rk PC jm, FM KL SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES , ENVIRONMENTAL HEALTH DIVISION JUL 1991 P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 NVI,'ONM NTAL HCAL-rT J 21RYIT EXPIRES _I YEAR PM. DATE ISSUED PEf?M1T/SERV10C,5 (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 coagFliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules amd Regulations of San Joaquin County?Public Health Services. y Job Address L �'` ry City Lot Size/Acreage ff�Owner's Name �, �'�' _ Address �—� 3 14a,4-c—V;0 Phone 4� 3`Z� Contract o � � � Address ibh(/lo _3za License No. :3 t/,n-2-- Phon `mss TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ Monitoring Well L7 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 Ind vial Cl Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing Momestic/Private Cl Gravel Pack 0 Tracy Type of Casing Specifications M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout 0 1rriUauon —.Approx. Depth ❑ Eastern uriace Saul installed by G Repair Work Done U Type of Pump �_ H,P.. �� State Work Done Well Destruction O Well Diameter Sealing Material i Depth t� Depth ! Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION M REPAIR/ADOITION Cl DESTRUCTION CI Mo septic system permitted if public sewer is available within 200 feet.) V Installation will serve: Residence— Commercial T Other Number of living units: Number of bedrooms ,+ Character of $oil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity— No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. b Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L1 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 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 shalt not 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, I shall ornploy persons subject to workman's compensa- tion laws of California." The applicant must call f II required in pections. Complete drawing on reverse side. _ Signed Title: _ ,p4---- Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date 7-/ 71 Additional Comments: < Applicant - Return all copiers to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. • EH 13.24 I11EV.1/"s1