91-0241 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 6&3 (209) 468-3447 PERMIT R M M RATE ISSUED (Complete in Triplicate) 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 9 City Lot"Size/Acreage � �_ Owner'ti NameRA-_�AAddress M0 Phone 9-3 Contractor ?J91)(17e� ! M i 3e;_3L� .__Address� I� • J/I 601A3 OJX License No..53 X Phone s�zo�g f TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ l PUMP INSTALLATION El rr SYSTEM REPAIR C7 OTHER ❑ 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 SPECIFICATIONS r� n IndustrialOpen Bottom D Manteca Die. of Well Excavation Dia. of Well Casing estic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S- Specifications ar ICl Other ❑ Delta Depth of Grout Seal _]� Type of Grout g tion " -.Approlx, Depth Eastern Surface Seal Installed by ork Done L7 Type of Pump H.P. j-� State Work Done _ Well Destruction 0 Wait Diameter Sealing Material i Depth `14 Depth Filler Material i Depth C ! TYPE, OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION M DESTRUCTION CI (No septic system permitted if public sewer is � available within 200 feet) " r r installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of axil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capecity No. Compartments PKG. TREATMENT PLT, Cl Method of Disposal _ Distance to nearest: Well Foundation Property Line �. + e LEACHING LINE Cl No. 8 Length of lines Total length/size FILTER BED n Distancetonearest: Well Foundation Property Line `- t 'SEEPAGE PITS 11 Depth I Size Number I SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 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 C0forniai" Contractor's hiring or sub-contracting signature cenifies 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," i The applicant must call for alt r_ired inspections. Complete drawing on reverse side. / Signed X .--f ! _ Title: Date: I F D TMENT USE ONLY i ,L � �^9 � Application Accepted by Date Area Pilot Gr ut inspection by ata Final Inspection by e#` ,FL:4 Data Additl al Comments: A — Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES " 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201 FEEI INFO AMOUNT DUE A OVNT REMtT7E0 CASH RECEkVEO BY DATE PERMIT'NO. r 9 EH 1,.� tREV.+ n sl , 3 s �a ; �- �r 9f _