SU0004712 SSCRPT - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 200911, STOCKTON, CA 95201 (209) 468-3447 PUAIT 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.17 Job Address Z AG 7s Sy City `��p Lot Size/Acreage l t/ Owner Ia Name `-.T-� Address ___ Phone Contractor Ad �y 17� License No372r Phone- TYPE OF WELL/PUMP: NEW WELL' WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE -3 FOUNDATION AGRICULTURE WELL OTHER WELL_S�� PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation / Z Dia. of Well Casin 6 'Domestic/Private XGravel Pack ' ❑ Tracy Type of Casing �� Specifications M Public Cl Other IJ Delta Depth of Grout Seal So Type of Grout C e e�- G trnpation 3 J_;" .Approx. Depth ❑ Eastern SuOace Seal Installed by Repair Work Done U Type of Pump X-0 H.P. �7 tet. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. b Length of lines Total length/size FILTER BED C.) Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 persona subject to workman's compensa- tion laws of California." The applicant must call for alt required inspections. Complete drawing on reverse side. Signed / Title: C2Z61_�_ Date:` Z-- 0— FOD EPARTMENT FODEPARTMENT USE ONLY ix y >6 c_ Application Accepted by // Date ` ` Area Z Pit or/Groyrt)inspection by� � Date 'LL— Final Inspection b 4--" Date'72 Additional Comments: _ Applicant – Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT 0 AMOUNT REMIF,fED � RECEIVED BY DATE PERMIT NO. . rH 0-24 IREV.k i A,31 cN