91-2945 - Laserfiche WebLink

Home Browse Search

i APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT 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. P(Job Address City Lot Size/Acreage Owner's Nam Address Phone Contractor - Address icense No. Phone TYPE ct WELL/P P: - NEW WELL ❑- WELL REPLACEMENT ❑ DESTRUCTION .❑_Out-of-'Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C3 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 CONSTRUCTION SPECIFICATIONS f7 Industrial ❑ Open Bottom [I Manteca Dia. of Well Excavation_ Dia. of Well Casing El Domestic/Private D Gravel Pack D Tracy Type of Casing_ Specifications Fl Public 1-1 Other F1 Delta Depth of Grout Seal Type of Grout I i Irrigation Approx. Depth l I Eastern Surface Seat Installed by Repair Work Done '0 Type of Pump H.P. State Work Done_. Well Destruction 0 Well Diameter Sealing Material A Depth I Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION INo septic system permitted if public sewer is ;. available within 200 feet.l Installation will serve: Residence— Coinirrlerciat— Other -0' Numberlof living units; Number of.bedrooms " Characte i of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 .Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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, 1 shall'employ persons subject to workman's compensa- tion laws of 51 at' a." The appy nt m t call for II required in ctions. Complete drawing an reverse side. ignedX � Title: Dater FO EPARTMENT USE ONLY f - Applica ton Accepted by _ ,1 Date Area Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: Applicarit - Return all copies to: San Joaquin County Public Health Services r -' Finvionmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEECK 8 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH 17.2 IREV.siw3t J' ,. � �O 7 t' �V 3O�� EH 14-M