SU0004500 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PE i- — - — --- SAN JOAQUIN COUNTY PUBLIC HEAT S&VICES ENVIRONMENTAL HEALTHDI ISIQN 445 N SAN JOAQUIN, PHONE (21 9)468-3420 P O BOX 2009, STOCKTON, A 952Q1 PERMIT EXPIRES 1 YEAR FROM ATE , ISSUEDD/�331� (Complete in Triplic t'6) f 7 Application is hereby made to San Joaquin County for a permit to construct and/orinstall 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. Job Address �� 7� C�� r/! e(f` City Lot Size/Acreage Owner's Name C // �� A L! Address Phone Contractor A&1,J, Address v r6Q�icense No v G Phone— G TYPE OF WELL/PUMP NEW WELL El WELL REPLACEMENT 11 DESTRUCTION Cl Out of Service well ❑ PUMP INSTALLATION O SYSTEM REPAIRKy OTHER O Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial O Open Bottom O Manteca Dia of Well Excavation Dia. of Well Casing )9.Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing__ Specifications tJ I'1 Public (1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Sedl Installed by Repea Work Done 1%;iJ- Type of Pump SCJ D- H.P. State Work Done WeN Destruction 0 Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.! Installation will serve: Residence_ Commercial_ Other t Number of kving units: Number of bedrooms Character of sone to a depth of 3 feat: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f SEEPAGE PITS 11 Depth Size Number r 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• nt's nature certifies the following: "I certify that in the W sig g: y performance of the work for which this permit is issued, I shall not � onniploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature ceriifiett the forowinp: "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 Cali The nt trust c I for allrequZired �specfions. Complete drawing on re side. Spned 2 Title: -6f S Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Arrea �J Pk or Grout Inspection by Date Final Inspection by Vv\ Dau Additional Comments: Applicant Return all copies to: San Joaquin County Public Health Services j Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE A OUNT REMITTED RECEIVED BY DATE PERMIT NO. I N A St 7HC� r7-- EM 1344(REV /S 7 S. EN / If tis / / � 1� A/</� 1 �0 7/ is ,! C - -