91-1153 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-'3447 PF�RYi'C MIRES k YEAR OROM DATE�NSUEQ (Complete in Triplicate) Application is hereby iaade.to San Joaquin County for a permit to construct and/or install the vork herein described--hi-a application is made in compliance vith San Joaquin County Ordinance No. 5119 and 1862 and the Rules apd`Ri3gurst�Tona of San Joaquin County Public Health Services. < S' CFO* Y Job Address Lot Size/Acreage p ) /�ki�/� � Phone Owner's Name f Address i • J /7r` �� License N0, 1521�5 Z Phone Contractor Address TYPE OF WELL/PUMP: NEW.WELL^ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service well ❑ PUMP iNSTALLAi ❑ SYSTEM REPAIR Cl OTHER El Monitoring well 1:7 DISTANCE TO NEAREST: SEPTIC TANK �� I. SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS L, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC 10 IS Cl Industrial ❑ pen Bottom 7--T anteca Dia, of Well Excav�40 ' Dia. of Well Casin t ❑ Domestic/Private ravel Packacy Type of CasingSpecifications M Public 1:1 Other Delta Depth of Grout SeType of Grout e �rngation ._._..Appfox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. State Work Done, Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material L Depth r� TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDITION M DESTRUCTION G INoseptic syst 200 feet.)permitted if public sewer isavailable installation will serve: Residence— Commercial_ Other Number of living units, Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ " - Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 8 Length of lines Total length/size k FILTER BED n Distance to nearest: Well Foundation Property Line f SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property line 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 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 st II f9r all igred inspections. Complete drawing on reArse side, qg� Signed X Title: Date: L FOR DEPARTMENT USE ONLY / Application Accepted by4k/ Date Area �� Plt or Grout Inspection by Date Final Inspec ion by ats S /7 91 Additional Comments: E Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTEO CK 9 ASH RECEIVED BY DATE PERMIT'NO. INFO ��} qr)�./// // + EH 13.21 IREV.IIRtii r 07<vc/ �� EH 44.28 F i