SU0005666 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION � Vy P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 REMIT EXPIRM I MAR PRQX DATE ISSUED (Complete in Triplicate) Application is hereby sade,t:a San Joaquin County for a permit to construct and/or install the work herein described. This application to made in compliance with San Joaquin County Ordinance No. 549 and .1862 and the Rules and Regulations of San Joaquin County Public Health Services. r Job Address ._ + 4 1 City�� Lot Site/Acreage Owner's Name Address 13119 1 k 4 Phone 0 Contractor_sr�eZ� aJ Address License No.fN4a52, Phone ). TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well 0 PUMP INSTALLATION D SYSTEM REPAIR 0 OTHER 0 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 SPECIFICATIONtf r �� L1 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavati n Dia. of Well Cosir► Domestic/Private Gravel Pack racy Type of Casing Specifications ae M Public 1:1 Other ❑ Delta Depth of Grout Seat Type of G ut 0 Irrigation ,_._...Approk, Depth 1] Eastern Surface Seal Insialled by p Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction Cl Well Diameter Sealing Material & Depth Depth .� /6'D Filler Material i Depth TYPE OF SEPTIC WORK: ..NEW INSTALLATION❑ REPAIR/ADDITION L7 DESTRUCTION M fNo septic system permitted if public sewer is . available within 200 leet.l installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feel: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Comparlments f PKG. TREATMENT PLT, Cl Method of Disposal Distance to nearest: Well - Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/sixe FILTER BED 0 Distance to nearest: Well Foundation Property Line (' SEEPAGE PITS 11 Depth Size Number Z SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby conify 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 raguiations`o1 the Son 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,,l 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 "sill for fl r r inspections. Complete drawing on rev side, 3 Signed Title: _.• i Date: ��J 1019:5F FPR DEPARTMENT USE'ONLY r2IApplication Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional.Comments. 6 Ale 1AI-e-iI /0'77 - �` —SO C'- Cr 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK f RECEIVED By DATE PERMIT'NO. EH—M 'ga'Ou'" 4"_ f8'