92-2558 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 1 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 XM FROM DATE ISSUM (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in cosrpliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San v Joaquin County Public Health Services. c� �C a- o ob Address JCity __,_ Lot Size/Acreage e4 Owner's Name TBgCP14 L LANQAddress ontraUor Address License No. Phone i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION r AGRICULTURE WELL OTHER WELL PITS/SUMPS F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dis. of Well Excavation Dia. of Weil Casing ` fa Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing—_ Specifications Il Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrioation —Approx. Depth I I Eastern Surface Seal lnstalied by Repair Work Done L] Type of Pump ' H.P. State Work Done_ Well Destruction ..k Well Diameter, Sealing Material i Depth Depth `� !'filler'lMaterial lk Depth d� TYPE OF SEPTIC WORK: NEW INSTALLATION I I A PAIR/ADDITION i I DESTRUCTION l I Wo septic system permitted if public sewer is available within 200 feet.i r Installation will serve: Residence Commercial_ Other Number of lMng units: Number of bedrooms Character of*ON to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ TypelMfg '� Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest:, Well Foundation Property Line LEACHING LINE ❑ No. S Length of lines- Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS It Depth ` Sire Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will ba 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 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." T I The a t must call for Mt required inspections. Complete drawing on reverse,side.-- - w ! Sigma Title: Date- PS ate: /` Z P R D RTMENT USE ONLY Applicatio Accepted by a et , v`^-- - _ "� Date 1- `p� Area Pit or Grout Inspection by Date Finale inspection by "` Data Additional Commence: • 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 CK RECEIVED BY 'D TE PERMIT'NO. INFO /�J A a EN 13-24(REV.I/A 5) tu0 ®,� / / F / EM 14.28 w,