92-3587 - Laserfiche WebLink

Home Browse Search

i 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 PERM[ T FIRES 1 YE FROM D T S /fid �V UED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the ►cork herein described. This application is made in compliance with San Joaquin County Ordinance No. 5149 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. 4City L k J ILA Lot size/Acreage Job Address r Owner's Name a n A {Address -3 �L -t 5 bwV� -- Phone �� Contractor JR -� y Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n kms, DESTRUCTION o out of Service Well 0 1 11. PUMP INSTALLATION ❑ SYSTEM REPAIR 11 STEM n tori DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. L1R FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' IIndustrial ❑ Open Bottom C3 Manteca Dia. of Well Excavation Dia. of Well Casing [1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Il Public F1 Other (1 Delta Depth of Grout Seal Type of Grout_ - I I Irrigation __Approx. Depth I I Eastern Surface Seal installed by n Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ._ ❑ Well Diameter sealing Material i Depth \ Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I i aNaitablalw shin system perfretted it public sewer is Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of sob to a depth of 3 feat: n. riy.a__ _ ` 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. & Length of lines Total length/size 4 FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS 11 Depth t Size Number SUMPS 0 Distance.to nearest: Well Foundation Property Line o 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 shall not employ any parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the fokowing: "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 mus alt 1 an r aired in . Complete drawing on rev se side. �� rZ Signed Title:-:- vim`' Date: ` FOR DEPARTMENT USE ONLY � Application Accepted by Data �7-f-2- �'�,Area �/ Pit or Grout Inspection by ate Final nspection by _9 Dots 1.- Additional Comments: Applicant - Return all copies t . 2San oaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEEs INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. . EH 1531 IR 7',$) �] FH 141.211