91-0741 - Laserfiche WebLink

Home Browse Search

s APPLICATION FOR PERMIT t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468--34473(/_M YEAR (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. �C Job Address /52 72C .4- K�eA V 0 [,. City Z=n Lot Size/Acreage V, Owner's Name /' 0C Address s Cri, Phone 62 Y,� Contractor�, Address License No. Phone TYPE OF UMP: NEW WELL Gl WELL REPLACEMENT 11 DESTRUCTION LJ Out Service Well ❑ P TION ❑ SYSTEM REPAIR U OTHE Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK WER LINES DISPOSAL PROP. LINE FOUNDATION AGRIC WELL R WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA SPECIFICATIONS f_1 Industrial O Open Bottom ❑ Dia. of Wall Excavatio Dia. of Well Casing �^ U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications - M Public i 1 p Delta Depth of Grout Seal Type of Grout CJ Irrigation Approx. Depth D Eastern Surface Seal Installed by Repair one U Type of Pump H.P. State Work Done ` We Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 0 DESTRUCTION GI (No septic system permitted if public sewer is available within 200 leet.I Installation will serve: Residence-A Commercial they Number of living units: � Number of bed ours Character of$oil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity U No. Compartments PKG. TREATMENT PLT,0 Methocl of D'%posal Distance to nearest: Well&04VF_oundaiion1Lz�KProperty Line LEACHING LINE M No. $ Length of lines 4 xTotall length/size i FILTER BED n Distan4a to nearest: Well ` Foundation to Property Line 2g)0 r SEEPAGE PITS It1"Depth Size " N mber SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 r 5X6 I hereby canify 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 cenifies 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 subjeci 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." 1 ,11 --- Thea licant mus call for al a Ire ' b { RP petitions, Complete drawing on,reverse side. Signed X Title: _____ Q .l�tu�/� Date: 4� I - _ FO PARTMENT USE ONLY �y / Application Accepted by Date _--rile _'�1 � Area or Grout Inspection by� Final Inspection by� � k Additional Commartts: ` Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN; P 0 BOX 2009, STOCKTON,-CA 05201 FEE INFO OUNT DUE AMOUNT flEMITTED CASH x If RECEIVED BY DATE PERMIT'NO. e EH 13,24 JREV.I/A5i 1r�� :� �� a •. �� EH 742$