92-2798 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Y 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 No. 549 nd 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ` Job Address T City t Size/ creage 1- Owner's Name �,�✓�� , �`�, , Address U Phone R ��. Contracts � ry"' '"�� Address ��G it License No.c �Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER,.LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL F PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications (I Public Cl Other rl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_X Commercial her 45 Number of living units: Number of bedr s Character of soM to a dept of 3 feet Water table depth r SEPTIC TANK. Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT.❑ �+ Method of Disposal Distance to nearest: Well � _ Foundation� Property Line 7s7 LEACHING LINE t No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS )Ii< Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 agnature 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 compensa- tion laws of California." The applicant must all for all required inspections. Complete drawing on reverse side. q Signed Title: 1 ♦,0,111 Date: '7`Z! FOR DEPARTMENT USE ONLY _6gEscstion Accepted by Dats 7 Area �v Grout Inspection by Date, Final Inspection by Date ` 1 �. NAdonal Comments: � -164 ,G^ Applicant - Return all copies to: San Joaquin Count Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IF EE 0 AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'N0. . EN 1344(REV.1/"a) t~v 114 l c ur v a4 - 944� I ?z �1 EH U-311U-311r kvl6o !i