90-2527 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES S ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 /�o Apll kk ifs (209) 468-3447 PRAT_ XURES I YEAR SROM PAIR I SSULD (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 ccWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County pPublic Health Services. V b Address Y�O� S fif_"0"1 /7 VE City S7�CTD14 Lot Size/Acreage ner's Name � . f�Nprr7f2r U l r`E41XAddress -910 `5 SCC?l?3N t9Uc. S7z7cK1UA3 Phone �ioS "�3 O ntractor S L^. _ _ Address y$03 JEC7J>j A vE , License No. Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT F) DESTRUCTION 0 Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well Q DISTANCE NEAREST; SEPTIC TANK SEWER LINES . DISPOSAL FLD, PROP. LINE ATION AGRICULTUll WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL EM AREA CONSTAUGTION SPECIFICATIONS n Industrial 0 Open Bottom Cl Manteca of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack. ❑ Tracy x Type of Coal 7t Specitications M Public 1-1 Other [IDelta Depth of Grout Seat Type of Grout 0 irrigation _.Approx. Depth ❑ Eastern t Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work pone_ Wait Destruction ❑ Well Diameter Sealing Material i Depth , Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION C3 DESTRUCTION A INo septic; system permitted if public sewer is ailabie within 200 feet.) Installation will serve: Residence�„- Commarciat� Other Number of living units: Number of bedrooms Character of soii to a depth of 3 feet: Water table depth r n SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 _ Method of Disposal — Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines: . Total length/size O FILTER BED n Distance to nearest: Well z Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property. Line r n DISPOSAL PONDS ❑ V ! 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 Horne 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 Cohlornia." 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 cap for all quire Inspections. Complete drawing on reverse side, Signed Title: <o W N E 12 Date: _ _9 _90 FOR DEPARTMENT USE ONLY p } Application Accepted by Date r++' �OAree a f 1 Pit or Grout Inspection by Data Final Inspection by W Date I S Additional Comments: Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 B 09, STOCKTON. CA 05201 iFEO AMOUNT DUE AMOUNT REMITTED CK N RECEIVED 9Y DATE PERMIT NO. • EM 13*174 111EV, i n sicPro c--, T I '? qZ2Lfoo—25 27 EM 7{•=a t�V4�y