90-3051 - 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 vMrm_ EXATRRS I. YEAR 990M DATE ISNED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This < application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. KjobAddress S " � r_`ORSE %'—W c City LODE Lot Size/Acreage 6 ,/Owner's NameErri LVCp _ Address s • o k-] � Phone 7 ! onlraclor Address License No. Phone TYPE OF WELL/PUMP'. NEW WELL ❑ WELL REPLACYAENT n DESTRUCTION ❑ Out of Service Well ❑ ` PUMP INSTALLATION ❑ SYSTEM EPAIR i_7 OTHER ❑ Monitoring Well DISTANCE TO NERREST: SEPTIC TANK SEWE INES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULT W LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO RUCTION SPECIFICATIONS r.1 Industrial ❑ Open Bottom ❑ Manteca D' . of Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack 0 Tracy Ype of Casin Specifications L7 Public 1. 1 Other ❑ Delta Depth of Grout Se Type of Grout Cl Irrigation __.Approx. Depth ❑ Eastern Surface Seal Installed b Repair Work Done ❑ Type of Pump H.P. State Work Done .' Well Destruction 1) Well Diameter Se Ing material i Depth Depth Filler Material i Depth. TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION DESTRUCTION G INo septic system permitted if public sewer is t available within 200 feet.] Installation will serve: Residence_y_ Commercial— Other Number of living units: __L.._ Number of bedrooms Character of soil to s depth of 3 feet: E Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line . LEACHING LINE ❑ No. & Length of lines r..-� — _.- _ Total length/size FILTER BED CI Distance to nearest: Well l 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 Dome 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 cerlifles the following: "1 certify that in the performance of the work for which this hermit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant $t call for all*rs , ed inspections, Complete drawing on reverse side. I1C Signed T Title: Date: VY- ` OR AR LY Application Accepted by <444aol Date Area Pit or Grout inspection by Date Final Inspection by Date 1,17 Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 88201 FEEINFO AMOU,NT DUE AMOUNT REMITTED CASH ECEIVED BY DATE PERMIT NO. .1 I EH 13.24IItEV.r/Mer EH 14.26 C..��