90-2886 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT /aid,. 1/:0- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL ,HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERHIT EXPIRES 1 YEAR 1999 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 "x application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public stealth Services. f 4 Job AddressCity Lot Size/Acreage: ,} Owner's Name 4&1 G yr Address Phone Contratlor � _ Address *i07fT/ _ License N� Phone TYPE Of WELL/POMP: NEW WELL ❑ WELL REPLACEMENT'n' + DESTRUCTION-0 Out of Service well ❑ ._____",.,,,,,•�P_UMP INSTALLATION,❑_,,.".,,,_,._,_,,,,.,_-SYSTEM REPAIfl,.K_ __.,,,,:� .OTHER-0_ 0�! t°ring`Well 0 i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ; PROP. LINE FOUNDATIONS AGRICULTURE WELL OTHER WELL---- PITS/SUMPS .T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1=] Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of'Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public C1_01her,_„t ❑ Delta Depth of Grout Seal Type of'Grout j Gi Irrigation Appro)j Depth ❑ Eastern Surface Seal Installed by Repair.Work Oone i.0 IFType of Pump H.P. State Work Done Welt Destruction O Well biometer. Sealing Material i Depth Depth i Filler Material i Depth 1 TYPE OF SEPTIC WORK: NEW WSTALLATION ID REPAIR/ADDITION�K DESTRUCTION Cl (No septic system permitted if public sewer is L --= available within 200 feet.) tnsialsetioh will Dve: Residence)-c- Commercial.r._, Other Number of living units: Number of bedrooms Character of soil to s4epth of 3 feet: C Water table depth SEPTIC TANK 'O Type/Mfg ' - Capacity. /200 6/f/No. Compartments PKG. TREATMENT PUT_Cl �h r r` Method of Disposal 7� OlMince to nearest.' -Well ___L y—�Foundstion 50 Property Line LEACHING LINE 1=l No. & Length of lines f) Total length FILTER BED ^-- -I (l Distance to nearest: Well - rD' Foundation y49 Property Line SEEPAGE PITS l Depth �-'� Sire_ _ h Number I ' SUMPS L1 Distance to nearest: Well 110 Foundation 9�O f 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 i 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 the[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 call for all required inspections. Complete drawing on reverse side. : 'Signed X rc._._.._ Title: __ �Q _t �- Date: OR DEPARTMENT USE ONLY I Application Accepted by .a, ,3k1,nm4a.n✓� Date ��•'�`�_ Area f 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 0 BOX 2048, STOCKTON, CA 95201 FEEC' INFO AMOUNT DUE AMOONT HEwTED CASH RECEIVED BY DATE PERMIT'NO. . EH t3:I4JREY. /NSI Y�1 q` ;�•$ ' It 0-0 ` l2 L� EM L