1108 - Laserfiche WebLink

Home Browse Search

,APPLICATION FOR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERM T 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 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 1i� City Lot Site/Acreage Job Address r/ ` N e�� 7 710 Owner's Name �� Address ._�� %0 WE ,� lit9 �_> ��— Phone ?rac,/r �,s-Z7 6 Contractor ry f(M Address O�GP - License No. &3 -� Phone 4 . TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ uut of Service Well ❑ PUMP INSTALLATION Er -_SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTH]N sKtL1r1.Ar1Vrr0 CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing n Domestic/Private ❑ Grave! Pack *Tracy Type of Casing_ Specifications. -- I'I Public 1:3 Other (-I Delta Depth of Grout Seal Type of Grout I I litigation .._._. Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Type of Pump�� H. P. �� — State Work Done - Sealing Material A Depth Well Destruction ❑ Wall Diameter Depth filler 14terial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (Nosepttrwthin 2013 fretsystem etted d public sawer is availableInstallation will serve: Residence — Commercial — Other Number of living units:. Number of bedrooms Character of soil to a depth of 3 feet: PAYMENT Watapya veIt a� — SEPTIC TANK. ❑ Type/Mfg Capacity No. ��'o1`1{my6is PKG. TREATMENT PLT. 0 methr7d>rJtr sal IN co 0 Distance to nearest: Wel! Foundation Proport�V1CI15 � M��S LEACHING LINE 0 No. & Length of lines Total iengt FILTER BED ❑ Distance to nearest: • Well Foundation Property Line SEEPAGE PITS _ I I Depth Size Number SUMPS YLI 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 must 11 for all required inspections. Complete drawing on reverse side. Signed Title: Date: Application Accepted by Pit or Grout Inspection by Additional Comments: f R DEPARTMENT USE ONLY ��-, '-�� J� Date �� Arse1..�`K- _. Date Final Inspection by AJJ Data Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 . IN 13.24 IREV. t/Ns IN 14.20 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. 11721