90-2962 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES '' ENVIRONMENTAL HEALTH DIVISION �1 P O BO% 2009, STOCKTON, CA 95201 \ (209) 468-3447 hERMIT 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 No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City Lot Size/Acreage 2 rO Owner's NameAddress ( w one c 3 i -SAO Contractor ' h AcItress P0-R Q`F 1"2 9A /T• License NoC��_Phones g-D r TYPE OF WELL/PUMP: ITEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well 0 DISTANCE TON EAR EST:--SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION '2—w AGRICULTURE•WELL�-- OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' ._ 'D Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Ca ' _ - LJ Domestic/Private ❑ Gravel Pack . O Tracy Type of Casing Specifications M Public Cl Other O Delta Depth of Grout Seal Type of Grout Irrigation �L Approx. Depth 0Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ c Well Destruction O Well Diameter Sealing Material i Depth ((_ \ Depth Filler Material i Depth + �U TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION Ci DESTRUCTION CI-1 N septic system permitted if public sewer is " available within 200 feet.! l Installation will sery R encs Commercial_ Other - Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: II Water table depth SEPTIC TANK O Type/Mfg h+ Capacity No. Compartments PKG. TREATMENT PLT, ClMethod of Disposal t' Distance to nearest:• Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/size FILTER BED 0 Distance to nearest:! Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number C SUMPS } LI Distance to nearest Wetl '' Foundation Property Line \ r DISPOSAL PONDS ❑ I hereby certify that t 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 person in such manner as to become subject to 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 compenia- tion laws of California." The applicant must call for all required inspectiana. Complete drawing on reverse side. t _ Sign Title: G Date: €€ ii i E f F DEPARTMENT USE ONLY Application iAccepted by _ 41u,_,.�(� 1� Date `\ �j Area Pit or Grout Inspection by Date Final Inspectio by Data MITAdditional Comments: t I _A Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 3lZoe(/ !-5 1`BCA� f rG�rPy / ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICi1kvr1Goi Ne)4 /y xej i,,ti•,cy l 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA '95201 rauGr /rvte�Po%• c, INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. I y. . EN 13•24{NEV.I/n sl 0,0—a P'\)�� �JY' b I