92-3865 - Laserfiche WebLink

Home Browse Search

i APPLICATION FOR PERMIT 4 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT-EXPIRES YE FR M DATE- ISSUED (Complete i-n Triplicate) t 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 covliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San Joaquin county Public Health Services. 303 f? �R�/ �v� __ Cit Job Address _ _ y /L/ Lot Size/Acreage k GG �_ I �g 21;1 'k Owner's;Name, Address _612d" �.,Ww wC Phone._ t a Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 14onitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 industrial ❑ Open Bottom ❑ Manteca % Dia. of Welt Excavation__ Dia. of Well Casing El Domestic/Private LI-Gravel Pack 0 Tracy Type of Casing_ Specifications 0 Il Public l-1 Other * F1 Delta _ Depili of Grout Seal Type of Grout V) I I Irrigation —.Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done U Type of Pump H.P.' State Work.Dane_ r Well Destruction ❑ 'Well Diameter Sealing Naterial i Depth1111, Depth Tiller Material i Depth = TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRJADDtTION I I DESTRUCTION I~I (No septic system permitted if public sewer is . . r - available within 200 feet,I installation willserve: Residence` Commercial the( Number of living units: Number of roo �- Character of soil to a depth of 3 feet: �"� _ _Water table depth SEPTIC TANK. ,f@-`TYPO/Mfg _ Capacity-2.,ega *FAY No. Compartments �+ PKG. TREATMEfVT PLT.❑ f F,, ;1111; 'Method of Di sal Distance to nearest: Well Foundation Property Line L— r LEACHING LINE + No. A Length of linea t I Totalgth/size FILTER BED CIDistanci to nearest: Wall Ir �undation, —f�property Line SEEPAGE PITS I 1 Depth t Size Number SUMPS Ll 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 Homs 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 taws 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 st call for all required inspections. Complete drawing on reverse side. q Signed Title: d Date: /,: 62 —/ 4 el F R DEPARTMENT USE ONLY Application Accepted by Date Area Pk or Grout Inspection by Date FinalInspectionb Dat Additional Commence: 4��?�� -� ..i ' °P �'��✓ ��E, Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services # 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO . EH,7-74(REV.I1 a 5)s� L t 0'� �� (� ✓ EH 11476