92-3842 - 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 P 0 BOX 2009, STOCKTON, CA 95201 PEMIT EXPIRES I YE FROM DTE ISSUED (Complete in Triplicate) Thi Application is hereby mcoupli Baa JoaquinCountyJoaquinfor County Ordinancermit to nNo..549 �ct o1662install and thethe Rules andherein Regulationsdof Sans applie ation is made in camp Jo�aquin County Public Health Services. 2[f �"S � �. ,City AAA Lot Size/Acreage A It Job Address .-rt . /�//� S #II f — Phone C�03 Owner ner°s Name - ' S" Address ' R F 771 P-r Phone 33 Y-4 7 Contractor �� CPZ >tg' Address r�� {7 License hio. TYPE Of WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION 0 Out of Service bell n Monitoring Well }` PUMP INSTALLATION �T SYSTEM REPAIR © OTHER ❑ [ SEWER LINES �-- DISPOSAL FLD. PROP, LINE DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION F" "'*---AGRICULTURE--WELL-�:--___ _OT.HER W.ELt_ - PIT.5lSU.MPS \ A_ INTENDED USE TYPE OF WELL PR09LEM AREA CONS f.fiUCTION-SPECIFICATIONS ��, - Dia. of Well Cising L7 Industrial ❑ Open Bottom f, ❑ Manteca Dia. of Well E a anon �C Specifications Domestic/Private Gravel Pack ❑ Tracy Type of.alting=- �- r. f"1 Delta Depth al Grout Seal` Type of Grout Cr'1 VI Public I.1 Other i I Illrrigation 3'ra_- .ApproK. Depth I I Eastern n Surface 5enl Installed by � _I_ State Work one _ f ' Repair Work Done L1 Type of Pump S��inB Material i Depths ' Well Destruction ❑ Well Diameter'" r '' 0 Depth i biller Material i Depth T�PE OF SEPTIC WORK: NEW INSTALLATIION I I REPAIRrADDITION I I DESTRUCTION_I I (No septic system permitted if pu,lic Sewer_is i rE availabja within 200 fust.)" ` Installation will serve:-Resident=s—�*,Com"w cwt�•"Other 4 Number of tieing units: ;Number of bedrooms r k`, I - Water table de th _ Character of soil to a depth of 3 feet: c i p SEPTIC TANK ❑ Typo/Mf f Capacity �- No. Compartments Y jF i �_--.,,Method of Disposal } PKG. TREATMENT PLT.❑ ' Distance tortdar t: Well Foundation Property Line l + LIEACHING LINE C1 No. iL Length of lines Total length/size �FILT�I - ER 8ED Ca . Distance to rtsarest: Wel! Foundation Property Line _^..- ' 0 l 1 Depth Number SEEPAGE PITS / - Sixt+ nea? Property Line SUMPS LI Distance tb rest: Well Foundation DISPOSAL PONDS ❑ ' 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 Joaqui9,,Couaty „ j Home owner or licensed agent's signature;certifies the following: "I certify that in the performance of the,work for which thin permit issued, I gna not bacome subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature employ any person in such manner as to' 'mance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- Gsrtif tea the following:"t unity that in the pettotion laws of California." The applicant mu w11 for all required inspectiotns. Complete drawing on reverse side. E Signed < < —'Title: QWJt►uZ Date: f Z` a� W.. .� . OR-DEPARTMENT USE•(3N4YM•.--.-----�------�---�-�----�� _•.,..,-.•-......-_....� Applron Accepted by tel- Date � w_ "FSate In 1 Pit or �r ut Impaction by �], Final Inrtpeetion b Dats Additional Comments: Applicant— Return all copies to:� San Joaquin County Public Health Services �- Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, St;kn, CA 95201 IFEE NF;] AMOUNT DUE AMOUNT REMITTED K RECEIVED BY D E PERMIT No. . EH 11-2 tREV.r INS) 6H 14`.36 ••J