90-2553 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT Y5 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR PRAM DATE ISSUID (Complete in Triplicate) Application is hereby made to Sam 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 A 0 sr kP_*_ A-1e:t s 0 L"e City LOD I Lot Size/Acreage Owner's Name K, pr� ` 5311 Address �.[l.&"tile L1 WIb6 44524 Phone " Contractor Add, License No AWV3Phon TYPE OF WELL/PUMP. NEW WELL, ELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C] OTHER ❑ Monitoring Well -� DISTANCE TO NEAREST: SEPTIC TANK �.� SEWER LINES � DISPOSAL FLD. N)A _ PROP. LINE JQ._ _ FOUNDATION S AGRICULTURE WELL _U9_ OTHER WELL_iU.._.. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation " Dia. of Well Casing ;6eDomastic/Private >&avei Pack ❑ Tracy Type of Casing Specifications M Public 1.1 Other ❑ Delta Depth of Grout Seal r Type of Grout IrP. 6aIAT 0 Irrigation Approx. Depth 0 Eastern Surface Sedi Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material 4 Depth O TYPE OF SEPTIC WORK: NEW INSTALLATION❑ AEPAIR/AOOITION 0 DESTRUCTION M (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms r Character of#oil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity----- No. Compartments PKG. TREATMENT PLT,❑ Method of Disposal ^ Distance to nearest: Well Foundation Property Line l LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS II Depth Site 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 workmari's compensa- tion laws of California." The applic must call for all r wired inspgctions. omplete drawing on reverse side. JII ,�A�y,� Signed Title:' /1C� 1516 1 MR Date: 9- �4_-1 FOR DEPARTMENT USE ONLY L' Application Accepted by Date �"12 /L Area Pit or lou Inspection by54 Date ' y 77-0 Final Inspection by Date f O Y' 0 Additional Comments: Applicant – Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTEO K RECEIVED BY DATE PERMIT'NO. • EH 13.24 IREV.I/A 51 EN 14.16 �� 3307