92-3229 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES '< ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 t' �Ea PERMIT EXPIRES 1 YEAR PROM DATE ISSUED (Complete in Triplicate) Application is hereby msde.to San Joaquin County for a permit to construct and/or install the voik`'herein described. This application is mode in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address a&—)Do !E�, a f City•x''1 � 6/_ of Size/Acreage Owner's Name 9a?&address �/ Phone Contracto c 4_19�ddres!'o_.6i& a �2 7r�� i gnie N�. - Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION O Out of Service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR Gll OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS IN DED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrisl O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications M Public I"1 Other p Delta Depth of Grout Seal Type of Grout CJ Irrigation Approx. Depth 0 Eastern Surface Seal Installed by 4 , Repair Work Done G& Type of Pump y�,,t H.P.3- State Work Done 70 Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material 4 Depth / TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is available within 200 last.) Installation will serve: Residence_. Commercial_ Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING UNE ❑ No. & Length of lines Total length/size FILTER BED E:) Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must ca red inspsctipns omplete drawing on re rse side. q, J Signed Title: Date: ! �c 1 2--- R DEPARTMENT USE ONLY G Application Accepted by Dat `� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE QPERMIT+NNO. . EH 13.24 IREV.I/n 5) C� s. e 4'r EH—2a