90-2468 - Laserfiche WebLink

Home Browse Search

APPLY CATI ON FOR PERMIT U SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION l� , P O BOX 2009, STOCKTON, CA 95201 l '0 1 (209) 468--3447 REMIT M1211195 1 YEAR PROM DATE MUM (Com Triplicate) (Complete in Application is hereby made to Sam Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquid County Ordinance No. 549 and 1862 and the Rules atsd Regulations of San Joaquin County Public Health�Services. L Job Address �� L..tsd-U _ — CityLot Size/Acreage is Address Owner's Name Phone_ _._ � Contractors vi e Address Z 4.., License No ' S Phone TYPE OF WELL/PUMP. t �n _NEW WELL.,❑. ,__WELL_REPLACEMENT 0 DESTRUCTION Cl Out of Service Well 01 .1 T 1 PUMP INSTALLATION O SYSTEM REPAIR 0 :OTHER ❑ Monitoring Well"'(.1 r DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES DISPOSAL FLD. : PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL .PITS/SUMPS .� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r 1 w n industrial D Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Welt Casing r CJ Domestic/Private CI Gravel Pack C] Tracy Type_of_Casing � Specifications, M Public f I'll Other .� �❑ Delta Y Depth of Grout Seal Type of Grout C3 Irnoation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump r H.P. State Work Done Well Destruction © Well Diameter 3eaiingwllaee , i Depth Depth Filler l Iter'Ik� l�& Depth u TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION DESTRUCTION CJ lNo septic system permitted if public sewer is available within-200 fest,} installation will serve: Residence Y Commercial— Other YA Number of living units: Number of Aedrooms �,=. . Character of soil to a depth of 3 feet:-... a Water table depth SEPTIC TANK D Type/Mfg �' Capacity— No. Compartments PKG. TREATMENT PLT. 0 _ Method of Disposal Distance to nearest Well �� .Found on'"" ,Propeny Line Yom{# 4 f C LEACHING LINE No. &.Length of lines T 40 €% '�'Totalore ngth/size C ` '�'/a/ Property Line . FILTER BED n Distance to nearest: Well _fes Foundation ,� f SEEPAGE PITS YI Depth Sire Number SUMPS LI Distance to nearest: Well Zap' foundation /d 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: "]-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." t k f The appiican ust tail for alt r uired•inspections, Complete drawing on reverse,sicis el/ f f Signed Title: � - - - - --- -. _ Date: .61.1 90--6 FOR DEPARTMENT USE ONLY Application Accepted by Date v Area Pit or Grout Inspection by Date Final Inspection by Data i Additional Comments: — I Applicant ^ Return all copies to: SAN JOAQU COUNTY PUBLIC HEALTH SERVICES -� `�. sPNVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES' 445 N SAN JOAQUIN, P O BOX,2009, STOCKTON„CA 85201 ' FEE AMOUNT DUE AMOUNT REM3TTED CIC 0 RECEIVED BY DA-ft' PERMITNO. INFO ) r CASH p �` I- . EH 13.24111Ey.i/ms) t 1 {_,/ („�iL 'r'�F�CJ / P Est^4.2a / k