92-3633 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 compliance with San Joaquin County Ordinance Ho. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public v alth Services. /�C LP y7 / Job Address _. r+ V ` _—— City ` +Got Si zzee/Acreage Owner's Name ..- MIA,pal' 8ics � �l . Phone , l � Address Contractor f~> S't Address J01V 7� License No. 77 � Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT r DESTRUCTION out of Service Well ❑ PUMP INSTALLATION& SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 7 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL �' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l# L1 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation 01 A.. Dia. of Well Casing v %;.k0omastic/Private -WGravel Pack q� 0 Tracy Type of Casing_ pvG Speciiicationa /c-Yd0 [1 Public 1-1 Other '? U n Delta T Depth of Gwur Se51 �� Type of Grout I I Irrigation! Z.f'�Approx. I epth I I Eastern Surfs a Saul Installed lip Repair Work Done U Type of Pump _ .S4-! _ H.P. St�t4 Wo;l�Done rrG t Well Destruction I� Well Diaeters Sealing Material Depth [�11,U/r47[ tZ m Ak / Depth Tiller Material i Depth' f TYPE OF SEPTIC WORK: NEW INSTALLATION 1 11 REPAIR/ADDITION I 1 DESTRU.CTION I 1 lNo septic system permitted if public sewer is available within 200 lest.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms ; Character of Will to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal R Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total tength/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth, Size Number SUMPS LI Distance.to nearest: Well Foundation Property Line ti DISPOSAL PONDS 0 1 hereby canify that.) have prepared this application and that 4he work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Cojinty Home owner or licensed agent's signature ceitifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature candies the following: "I certify that in the perfofrna'nce of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant mus call for all required inspections. Complete drawing on reverse side. Signed x 'Title: dC. A-el< Date' �" `• NJQ' DEPARTMENT USE ONLY12— Application Accepted by Date F Z- Area �- i I{ Pit or Grout nspection by Date I f �/ Final Inspection by Dats r /� Z, Additiorral Comments: 14-10 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PER L4 R • EN11t1IREY.rresi P& 1 Q r©� q „ �Z EH ls•ze ` t f( 1 WD 92