91-0140 - Laserfiche WebLink

Home Browse Search

r APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PRUIT EXPIRES 1 YEAR PROM DATE, ISSUED (Complete in Triplicate) Application is hereby sade to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address is-.2L Fa+, rx City.'57-& Lot Size/Acreage FPre-la.�_>o E Owner's Name .192ei' .Pii1,412.0 Address S h,� ^ Phone ' Contractor G Address JP- y.3 flee ,gam, License No. /:6-1;4 Phonel- I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION 0 SYSTEM REPAIR D OTHER 13 Monitoring Well C.3 DISTANCE TO NEAREST: SEPTIC TANK^ SEWER LINES DISPOSAL FLD, PROP, LINE F FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL r PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom Q Manteca Dia. of Well Excavation Dia. of Well Casing LJ Domestic/Private D Gravel Pack n Tracy Type of Casing Specifications M Public i.1 Other ❑ Delta x Depth of Grout Seal.' =• Type of Grout 1+ CJ Irrigation ; Approx. Depth ❑ Eastern Surface Seal Installed by lJ Repair Work Done C3 Type of Pump H.P. State Work Done Well Destruction 0 , Well Diameter sealing Material & Depth y✓ Depth Fiber Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDITION W DESTRUCTION G (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: :,'Residence L__ Commercial`_ Other _ Number of living units: Number of-bedrooms Z Character of soil to a depth of 3 feet: '' Water table depth SEPTIC TANK 1 ❑ Type/Mfg' Capacity No. Compartments ! t PKG. TREATMENT PITT. 0 Method of Disposal Distance to nearest: 1 Weft' Foundation Property Line LEACHING LINE - No. &ten th of lines ' _ g Total length/size FILTER �- BED n� Distance to nearest: �Well ��;,;-Fouradation- SEEPAGE PITS r.�Y Depth' _Si,-, 3.1 Number SUMPS LI Distance to nearest: Well��_ Foundation Al Property Line S ' I DISPOSAL PONDS O I hereby certify that I have prepared•this'application and that the Work will be done in'`dcoidance with San Joaquin county ordinances, state laws, and rules and regulations of the Sen•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 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 employ persons subject to workman's compansa- tion laws of California.,. a The applicant mcall for all required inspections, Complete drawing on reverse side, Signed hl,�t Title: =. Date: } l Z _ 9/ OR DEPARTMENT USE ONLY Application Accepted by Date -_aZ 9 Area ` Pit or Grout Inspection by Date Final Inspection byC7 Dats � Additions Comments: t v� Applicant - Return all copse to: SAN JOAQUIN COUNTY PUS HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 3 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT RTeo EM)TCASH RECEIVED BY DATE PERM17'NO. EH 1 .24 Me .�iMbi r ,l j _ R ��1 i�O i EH 4.26 -01, b1o M .�