91-1476 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-&W34-12-0 � PERMIT EXPIRES 1 YEAR VR(?XLP.AJE I.SSUEi? (Complete in Triplicate) Application is hereby trmade,to Sen Joaquin County for a permit to construct and/or install the vork herein described. This application is made in coWllance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City Lot Site/Acreage Owner's Name ZO Address �y �1 / Phone Contractor a AddressLLnnag4o� 1'4ku�JJh 1,5;3 license No.saL�� Phone X96 TYPE OF WELL/PUMP: NEW WELL,, WELL REPLACEMENTJK DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 0 Monitoring Well (.1 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 f_l Industrial O Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing >omestic/Private XGravet Pack E] Tracy Type of Casing Specifications M Public la Other ❑ Delta Depth of Grout Seal Type of Grout 0 lrripation —Approx. Depth ❑ EasternSurfs Seal Installed by Repair Work Done U Type of Pump H.P. 1,S State Work Done _ `• Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ ,REPAIRIADOITION M DESTRUCTION G (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 Capaeity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/sizeN FILTER BED 0 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 perlormance 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." f The applicant=If for all requir pecti s. Complete drawing a reverse side. JQ, Signed itle: _ Date: F EPARTMENT USE ONLY // Application Accepted by Date b" Area Pit or Grout Inspection by Date 2f J Final In action by a[a `t2 Additional Comments: ` Applicant - Return all copies to: SAN JOAQUIN COUNTY Pill I'C HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 SOX 2009, STOCKTON, CA 98201 N AMOUNT DUE AMOUNT R/E�MITTED X I CASH RECEIVED BY DATE PERMI'T'N^O�. EN 13-24 Od oo I + f T.� 1171- EN ;,.m I I [ l L