92-3717 - Laserfiche WebLink

Home Browse Search

ICS.• A- fu' 4` ✓1 f t Ac APPLICATION FOR PERMIT SAN JOAQUXN COUNTY PUBLIC HEALTH SERVICES 1 P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PMI`I' EMIRES 1 YEAR rROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and ReVlatione of San Joaquin County Public Health Services. Job Addrbul� �C ✓� City �Lilt7brl I.ot Size/Acreage Owner's Neme ( AlrrO �� dd Address _e00 py"6 ,4 f =a1VPhone Contractor cl Address � License No 2-2- tr Ptiene Q` TYPE OF WELL/PUMP: NEW WELL ❑ WELL A PLACEMENT ❑ DESTRUCTION 0 Out of Service Well 0 r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER fX 1:4MES��Well L DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. L,di, s FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ 0 lyldl_ l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (/ f-1 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack n Tracy Type of Cas'n Specifications M Public C1 Other ❑ Delta Depth of t 1t__�_ Typa of Grout Ci Irrigation _.Approx. Depth ❑ Eastern Surf ce Seul InstalCad by- G,r,- r .fk�h�� J Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE Of SEPTIC WORK: NEW"lumber STALLATION 0 REPAtRIADOITION 0 DESTRUCTION C1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residen — Commercial_ Other Number of living units: of bedrooms Character of Boit to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity IN C mpartments PKG. TREATMENT PLT. C3 Meth of Disposal Distance to nearest: Well Foundation Property Lin LEACHING LINE Ci No. b Length of lines Total length/size . r FILTER BED I::I Distance to nearest: Well Foundation Property Line SEEPAGE PITS II Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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, an 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 tiny 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 lawn of Californla." The applicant t call r all r Kuired inspect S. Complete drawing on re a sa sib Signed } LL/ Title: Date; FOR D PA MENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date I fI 1 Additional Comments; ID IL] �� t Applicant - Return all copiee to: SATE JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOR 2009, STOCKTON, CA 85201 FEE AMOUNT DUE INFOAMOUNT REMITTED RECEIVED BY y CASH DA PERMIT NO.