90-3355 - 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) 468-3447 Y R (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 trade 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 v Qd City Lot Size/Acreage Owner's Name 'V\- ,S 2,) V Address _ CQ �� - 41�,S5 012 Phone 93 4_92 ` k Contractor �_l 4 Address R n1m e License No. Phone TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well [7 ' 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"� SJ 0 Industrial ❑ Open Bottom ❑ Manteca Dia.uof,Well__Eica`Vation"`""'' Dia. of Well Casing U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications M Public (.1 Other ❑ Delta Depth of Grout Seal, Type of Grout 0 Irrigation ,_._,.Approx, Depth ❑ Eastern SuAace Seth"Installed}iiy_ ='`"�"'" ' Repair Work Done U Type of Pump H.P, State Work Done Well Destruction O Well Diameter Sealing Materta—A Depti Depth Filler Xaterial 4'Depth � TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIWADDITION CT DESTRUCTION CI lNo septic_system_permitted if public sewer is available within 200 feel,I Installation will serve: Residence��Commercial— Other , Number of living units: " Number of bedrooms 2 Character of soil to a depth of 3 feet Water fable'depth SEPTIC TANK ❑ Type/Mfg A. cla—bo No. Compartments PKG. TREATMENT PLT. 0 f 1 *Method'of Disposal '�T ,Distance to nearest: Wel1 �Foundation Property Line LEACHING LINE IrNo. & Length of linesTotal length/size �) FILTER BED n istance to nearest: Well 3�r'� Foundation Property Line ^'f SEEPAGE PITS I I Depth '� Sire 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 performance of the work for which this permit is issued, I shall not employ any person in such manner as t0 become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the perfofmanre of the work for which this permit is issued, I shall employ persons subject to workman's compensa- lion laws of California." The applicant ust nail for all required "cctions. Complete drawing on reverse side. �7 �} Signed x _ L< / _ t C�C��CZ�" _ Title: Date,`- Z 9—c-) / — 0' FOR DEPARTMENT USE ONLY ^7 Application Accepted by ' ` Date _ Area Pit or Grout Inspection by Date Final Inspection by 46� w Date 12,12rl9o, Additions[ Comments: Applicant - Return all copies-to., SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE IA/MOUNT REMITTED ASH RECEIVED 9y DATE PERMIT'NO. fH 13 EH 1420