91-1003 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT S SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1� P O BOX 2009, STOCKTON, CA 95201 �Co (209) 468-3447 YEAR (Complete in Triplicate) Application is hereby rands to San Joaquin County for a permit to construct and/or install theiwork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public H^t�alth Services, ' / ` Job Address - T J -� ��-- hJ (2-R City Lot Sine/Acreage 11 \a .� �. Address `� -Phone Owner's Name s A Conlraclor� Address License No, Phone - TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well—Of ell ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Mon oring Well DISTANCE TO NEALWEK EPTIC TANK SEWER LINES DISPOSAL FLO, LINA: FOU AGRICULTURE WELL OTHER W PITS/SUMPS INTENDED USE TYPE OF WELL M AREA CONSTRUCTIONICATIONS F industrial III Bottom ❑ Manteca ia. of xcavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy e o Specifications C=f Public I Other D Delta Depth of Grout Se Type of Grout CJ Irfioation �,.ApproKDepth astern 5tiririca Seal Installed by Repair Work Done U Typs of Pum H.P. State Work Done _ Wall Destruction © Well - star Sealing Material i Depth pth Filler Material i Depth TYPE OF SEPTI ORK: NEW INSTALLATION Cl REPAIR/ADDITION M OESTRUCTION_V iNo septic system permitted if public sewer is available within 200 feel,l f installation will serve: Residence — Commercial— Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No, Compartments PKG. TREATMENT PET. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size 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 to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracting 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 workman's compensa- tion laws of California." _.�..The_applicant•must call for all required inspections, Complete drawing on reverse side. '(Signed Date: 5i- Title: --- FOR DEPARTMENT USE ONLY T _ApplicationAccepted by Date 5-3 /;.__..._Area. --- Pit or Grout U Inspection by __ Date Final Inspection by Date G +p r Additional Comments: �` 3 L I ® ' Applicant - Return all copies tot SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOR 2009, STOCKTON. CA 85201 FEE AMOUNT DUE AMOUNT REMITTED CK8 PECEIVEO By DATE PERMIT NO. INF�O �} CASH IREV.,/.0)S{'I,.J [ ©' 0b 1 i i 3 1 EN;ode