91-1673 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT x SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ,.ENVIRONMENTAL HEALTH DIVISION :*r •" P O' BOX-2009, STOCKTON, CA 95201' (209) '468-3447 r'Y R - ATR I SSIT (complete in Triplicate) made,to San`Joaquin County for a permit to construct and/or install the work herein described. This application is made in cce�rliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Appllcatioa is hereby Joaquin County Public Health Services. City Lot Sire/Acreage Job Address 7 Abutter Owner's Nema Address ` - Address A � License N�-Phone Contractor — YPE OFWELL),-PUMP: NEW WELL ❑ WELL RECEMENT ❑ DESTRUCTION ❑ Out of Service well DESTRUCTION- Monitoring Well SYSTEM REPAIR ❑ OTHER ❑ l PUMP INSTALLATION El DISPOSAL FLD. PROP"LINE DISTANCE TO NEAREST:'SEPTIC TANK SEWER L1NES• { -ter - r t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �. INTENDED USE TYPE OF WELL PROBLEM AREACONSTRUGTION SPECIFICATIONS _ --�-- pia.of Wejl-Cesing Cl Industrial s ❑ Open Bottom ❑ Manteca I-Dia. of Well Excavation Specifications 3 �T a U Domestic/Private Cl Gravel Pack ❑ Tracy yp of Cas in g } Type of Grout Depth of Grout"Seal Y ❑ Public -}� I:1 Other ❑ Delta S s ,.Approx. Depth C] Eastern Surlace seal installed by l CJ lrrigauon State Work-Done Repair Work Done�`L7 Type of Pump H•P t - r P Sealing Material & Depth . SWell Destruction € O Well Diameter - 4 I Depth Piller Materiel & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION DESTRUCTION OI avail ble.wittic hin 200 feet') it public sower is F /IAI L+ . I Installation will serve: Residence Commercial____ Other,, , I Number of living units: Number of bedrooms-_ I Character of soli to a depth of 3 feel: .._ ` Water table depth ` "n SEPTIC TANK rte ❑ Type/Mfg' af- Capacity No. Compirtta _ `' � Method of Disp0"'Sal PKG, TREATMENT PLT. r Distance to nearest: , , Well Foundation Property Line LEACHING LINE Cl No. & Length o} lines Total length/size J r FILTER BED ❑ Distance, to nearest: I Well Foundation Property Line Number. SEEPAGE PITS Depth Sire `- SUMPS L'I Distance to nearest: Well Foundation Zv,�- Propefty Lina DISPOSAL PONDS t� ❑ ' - r I hereby certify that I have prepared this application and that the work will be done'.In-accordance withSan JoaquicounY ordinances, state laws, and rules and regulations of the San Joaquin County •r"r I Home owner or licensed agent's signature certifies the Iollowmg: "I certifky:.that m,the performance of the work for which this permit'is issued, I shall not a employ any person in such manner as to become subject to workmen's-compens8tion laws of California." Contractor's hiring of sub-contracting signature i certifies the following: '•1 certify that in the performance of tfie work for which tliis permit is issued, I shill employ persons subject.to workman's campensa• tion laws of California." \ ` I The applicant must call for all required i tions_. Complete drawing'dh reverse side; r:. / rJ f Title, Date: Signed t ! f;OR DEPARTMENT USE ONLY I f Date ✓j % 'Area 1. Application Accepted by rr , r Plt r Grout Inspectian by 'Date t' Final tnspectian by ✓. ` Data dditlonal Comments: Applicant - Return'Ll-I copies to: $AN JOAQUIN COUNTY ZUB41C-)kRALTH SERVICES r, r i ENVIRONMENTAL HEALfi DIVISION PERMIT/SERVICES 4 � r 495 N SAN JOAQUIN, f? O SOX 20r��," 9TUCKTON, CA 95201 � t CK -/ FEE AMOUNT DUE^ K AMOUNT REMITTED CASH RECEIVED BY DIATE PENMlT NO, INFO� ` r 3 .�EH1�741REV.t/w31 l EM A•ZII o-