92-3046 - 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 O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby, ands to San 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 � Joaq��ty�blie Health Services. Job Address !p � City Al I�ot Size/Acreage _ Owner's Name "" "/ adress Phone Contractor ' r►/1 Address J 1,.)o cfl Rc�en�seNo �2_ ` Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring ell DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 4R(SrLE�� tl FOUNDATION AGRICULTURE WELL OTHER WELL PITS—/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing Cl Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout I I Irritation _ApproJ Depth i I Eastern Surface Seat Installed by r Repair Work Done LJ' Type o1 Pump H.P. State Work Dons Well Destruction ❑ Well Diameler Sealing Material L Depth Depth Filler Material i Depth yTYPE Of SEPTIC WORK: iNEW INSTALLATION I I REPAIRIADOtTION I I DESTRUCTION [ I (No septic system permitted it public sewer is i t ' available within 200 feet.) + Installation will serve: Retsidence_ _' Commercial____ Other Number of living units: a `Number of bedrooms Character of soil to i depth�of-2 feet: --- water table depth l SEPTIC TANK . ,� O\ Type/Mfg, Capacity I No. Compartments C PKG. TREATMENT PLT.Ll l r t=y Method of Disposal Distance to nearest: Well # _.. -Foundation Property Line LEACHING LINE Cl No. III Length of line`s s Total length/size - FILTER BED ❑ Distance to nearest. WeU Foundation Property Line J SEEPAGE PITS I I Depth r1 Size Number r SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ i i III I hereby certify that I have prepared this applicition end that the work will be done in accordance with San Joaquin county ordinances, state laws, and I rules and regulations of the San Joaquin. County Home owner or licensed agent's signature certifies the following: ';t 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 unify that in the performance of the workfor which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Californla." F The applicant ust call for all r utred inspections. Complete drawing on reverse side. : 5rpnedp , Title: t Date: 1 FOR DEP ENT USE ONLY Application Accepted by -- =��s�001;& —A Date `.Z` ea t Pit or Grout Inspection by Date Final Inspection by Data i } �: /1 Addition-at Comments: i/ Applicant,- Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445.N San Joaquin, P 0 Box 2009, Stkn, CA 95201 INFO AMOUNT DUE } AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. FEE . EH 13.24 IIIEv.i i e 5r e CH tl•7e k