91-1145 - Laserfiche WebLink

Home Browse Search

f APPLICATION FOR PERMIT SMI JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) ,468-3447 R (Complete in Triplicate) IF Application is hereby made to San Joaquin County for a permit to construct and/or install the Work herein described. This application Is made in cot*liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. (� T,,2 I a � Job Address .i. � ` �1..TJ --- -• City - Lot Size/Acreage �� a e i Owner's Name Address Phone ContractorL - -• R _ _ H Addre.SS �" License No.��-3� Phone r�-=�' ` TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT X DESTRUCTION ❑ Out ofiService Well Gl PUMP INSTALJLATIONX SYSTEM REPAIR ❑ OTHER O Monitoring well C DISTANCE TO NEAREST: SEPTIC TANK' "Er SEWER LINES DISPOSAL FLD. �� PROP. LINE a l FOUNDATION ^r AGRICULTURE WELL OTHER WELL PITS/SUMPS ._ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottoniv ❑ Manteca Dia. of Well Excavation Dia, of Well Casing XDomeslic/Private C1 Gravel Pack ...0-Tracy Type of Casing Sx� 4f / - Specifications € I M Public 1 is Other ' [ Delta Depth of Grout Seal +� Type o Grout G Irrioation 1:91WApprox...-Depth ❑ EastarnIr Surface Seal installed by t Repair Work Done U Type of Pump -SM.P. State Work Done Well Destruction Well Diameter Sealing Material i Depth----- Depth. epth--- Depth Filler Material i Deptht��aA, t9 TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION CT DESTRUCTION CI (No septic system permitted if public sewer is R _ -_I available within 200 lest.) Installation will serve: Residence Commercial____• Other Number bf living units: Number of bedrooms Character of soil to a depth of 3 fest: Water table depth SEPTIC TANK. O'� Type/Mfg Capacity TNo. Compartments PKG. TREATMENT PLT. Q Method of Disposal F �� Distance to nearest: Well Foundation t Property Line LEACHING LINE ❑ No. & Length of lines - _ Total length/size r FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PIT5�.__ Y I I.__.Dopth Size --- — Number-.---- SUMPS Ll Distance to nearest: Wel Fobndstion Property Line DISPOSAL PONDS ❑ I hereby c,hify 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 subcontracting signature eertifisi`the following: "I certify that in the performance of the workyfot which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ' The applicant must cal for all require4 inspections. Complete drawing on reverse side. Signed '` Title: cr-f V_Ite<, Date: -� 1 � FOR DEPARTMENT USE ONLY Application Accepted by ` Date Area Pit or Grout Inspection by l/, Date _ Final Inspection by , - -- - ---- - Dat,' Additional Commence: ' d&u ( j Z•�f 3 _ 'Applicant Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES _......945.N SAN-^JOAQUIN,-P-O BOX-2009,•.STOCKTON.,.CA-95201FEE INFO AMOVNT DUE AMOUNT REMITTED ASHD $RECEIVED BY DATE PERMIT'NO. + VqW EH 1]-241REV. 5) rIMP-- 4 i � EH 14.20 -OD _