SU0004712 SSCRPT - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ,. P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PE1WIT 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 coaopliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �� Job Address /-✓` -3 a)/Q �jy C/iJty 177p6 Lot Size/Acreage .� Oi Name <2 �"v'Address �vU lJ(� l /[-x - Phone Contractor 055 k»11f Address) 3 /J•L!n c ob,) License No. 55306 7 Z Phone � l S�2o y� TYPE OF WELL/PUMP NEW WELL / WELL REPLACEMENT O DESTRUCTION O Out of Service well O PUMP INSTALLATION JY SYSTEM REPAIR ❑ OTHER O Monitoring Well C� DISTANCE TO NEAREST: SEPTIC TANK /00' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE.-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl Iu trial pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications r M Public 11 Other O Delta Depth of Grout Seal T,ype of Grout + 0 IrriUauon — Approx. Depth 0 Eastern Surface Seal Installed by zi -A-: Jam` I UJ Repair Work Done U Type of Pump )Q:�I - H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth r S \ ,r/}� Depth Filler Material i1 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION F-I (No septic system permitted if public sewer is available within 200 feet.) ^ Installation will serve: Residence _ Commercial — Other J Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. O Method of Disposal r. Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Length o1 lines Total length/size FILTER BED CI 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 cenify 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 persons subject to workman's compensa- tion laws of California." The applicant must call or all r ed inspections. Complete drawing on reverse side. Signed X Title: �hJ Date: / 2 �Ak JQA DEPARTMENT USE ONLY i Application Accepted by rK S �� C`^ Date L Area Q �r Pit or ro Inspection by r Date s Final Inspection by-1 ��1---f-'--"' Date 4+ "' 15 f / Additional Comments: - 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 95201 FEE AMOUNT DUE AMOUNT REMITTED CKRECEIVED BY DATE PERMIT NO. INFO, CASH . EH 13.24(REV. i n s)