SU0004712 SSCRPT - Laserfiche WebLink

Home Browse Search

APPLICATION FORT PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONI[ENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 / PFAMIT EXPIRES 1 YEAR VROM 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 in made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. n Job Address r�+�? 64/10 S Cit Lot Size/Acreage � � Y- Owner's NameL yt 0"rr y Address sc 4 z - Phone Contractor FV It cl Address_ n p ox, 1qJ License No.�7 ��_Phone ✓ �) TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER ❑ 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 f1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications * Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout M Irrigation Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Depth Depth Filler Material i Depth l/ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION L1 DESTRUCTION CI INo septic system permitted if public sewer is _ available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: 1 Number of bedrooms U Character of soil to a de�p/tfy of 3 feet: e,l1yi�if'1 Water table depth SEPTIC TANK td Type/Mfg f4-L, C-0Yis/oTe- Capacity I Ce O No. Compartments PKG. TREATMENT PLT. C1 i I Method of Dispgsal Distance to nearest: Well 00 Foundation. _ Property Line 5 LEACHING LINE No. 6 Length of lines _ kb Total length/size 1 FILTER BED CI/Distance to neared: Well Foundation .5Property Line S� SEEPAGE PITS U' Depth � 3 Number SUMPS LI Distance to nearest: Well _L�Q Foundation _ '!7,<_ 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 subcontracting 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 Inas of California." The applicant must call fora required inspections. Complete drawing on reverse side. C. Signed _� Title: 5 x'11' Date: FOR DEPARTMENT USE ONLY Application Accepted by C�� Date Area or Grout Inspection by _ ate kis-_C11' _ Final Inspection by Date Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 3 445 N SAN JOAQUIN, P O BOX 2009, STUCKTON, CA 95201FEE r INFO AMOUNT DUE AMOUNT REMITTED CASH CK I RECEIVED BY DATE PERMIT N0. \ . cMQ-24�Rt:v.,,x,; �f/ '��C.;L: -- tv--