91-0512 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT �, .. rf x I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESWh ; ENVIRONMENTAL HEALTH DIVISION nt+. P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447PERMIT M21995 1-YEAR _WM DATE _MUM (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. j Job Address it Lot size/Acreage Owner's Name � Address Phone �-r Z)7- r s " License No. Phone TYPE OF WELL/PUMP: NEW WELL-'n WELL REPLACEM T 0 DESTRUCTION C1 Out of Service Hall C1 PUMP INSTALLATION SYSTEM REPAIR :❑ OTHER ❑ Monitoring cell C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 7 DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .�...9..., _�. -�-- -. .__ INTENDED USE TYPE OF WEL. _ w L PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca - Dia, of Well Excavation Dia of Well Casing j ;;>�,mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public 1:1 Other ❑ Delta Depth of Grout Seal Type of Grout CI Irrigation ^LApprox. Dep 4hh stern ISp�ce Seal Installed by Repair Work Done LD Type of Pump�r �7 H.P.S `� State Work pone _ Well Destruction 0 Well Diamete Sealing Material i Depth Depth FiTler•Material & Depth TYPE OF SEPTIC,WORK: NEW INSTALLATION ❑ REPAIR/.ADDITION-M DESTRUCTION CI (No septic system permitted if public sn-war is r k available within 200 test.l � b Installation will serve: Residence— Commercial Other' Number of living units: Number of bedrooms Character of soil to a depth of 3 feat: ' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments M PKG. TREATMENT PLT. 0 :i Method of Disposal Distance to nearest: Wel! Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total Ienpth/size j, FILTER BED n Distance to nearest: Well : 'Foundation Property Line SEEPAGE PITS l I Depth Sue ^ Number SUMPS E l Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r. = . - 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, an rules and raguiti0ons 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 employ any person in such manner as to become subject t3 workman's compensation laws.of.California," Contractor's hiring or subcontracting 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 st caN or el iced 'nsp®ctions. Complete drawing on r rse side. ' ,�// X�b C Signe VO`�' Title; Date: FOR DEPARTMENT USE'ONLY Application Accepted by ra 1.01 _- � Date _ Area Pit or Grout Inspection by Date Final Inspection bDate�Z� Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES tom` i 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH r7 (] . EH t]•24IREV.I/M5I {��_ 00 .Ci t� EH 1,4.26 i °s