92-3818 - Laserfiche WebLink

Home Browse Search

iAPPLICATION FOR PERMIT z P-4 s SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 r �►N J.OAQUIN, PHONE (209)468-3420 P cJ, J-A;S 20(io, STOCKTON CA 95201 , rr 1J�rtp9 f PERMIT EXPIRES I YEAR FROM DATE ISSUED '-s-u _ :(Complete in Triplicate) C,;�-19 ( ( Application is hereby mede.to San Jdaquin County for a permit to construct and/or install the work herein described. This application is made in coWliance with San�Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San ` Joaquin County Public Health services. i ii f-> n �+ 5,� XiaoB�a 1�03 . W , `[ .'_ ' 'City' Lot'size/Acreage Job Address r �� •. ►�Or:- one Owner's Nam _ + `� � '. L;cense No. �X -74, Phone dog' 910 S. Address- ConEract TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C DESTRUCTION Cl Out of service well 0 PUMP INSTALLATION N ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC"TANK "" " SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL ' PITS/SUMPS INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS e L1 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing V Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of.Casing_ Specifications 11 Public fI Other 1-1 Delta Depth of Grout Seal Typa of Grout 1.1 Irrigation Approx Depth " I 1 Eastern -Surface Seal'Installed by _Repair"Work Done v Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter'f" �ealing Material L Depth Depth ( 1l ler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR ADDITION DESTRUCTION I I available within system permitted if public sewer is, - AM Installation will serve:.,.Residence i iCommercial-2< Other Number of living units: Number of 44roorns Character of colt to.a depth of 3 fest: t Water tabs depth r SEPTIC TANK ❑' Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. CI cy Method of Disposal 1 Distance_to nearest: Well Foundation. Property Line 1 lI LEACHING LINE L-1 No. 5 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i If Ttt►r6 SEEPAGE PITS Depth Size Number SUMPS f Ll Distance to nearest: Well }' Foundation -- Property Line DISPOSAL PONDS ❑ 1 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 shell not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 applican st call f req 'ed inspections. Complete drawing an reverse side. 0 111 Signed Title: I P _ Date: r OR DEPARTMENT USF ONLY l Application Accepted by ± Date !�� -- Area 1 L - Pit or Grout Inspection by Date ,nal Inspection by Date 1 'A- Additional Comments: S Applicant - Return al copies to: San Joaquin n Public Health Services VOW Environmental Health Permit/Services t� ♦� t 445 H San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMDUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. INFO � r p r 1� - �. EMt�- IREY.r/tisl i f �'� r0^D �7 "� �/ 4 EM 14•aia i