91-0504 - Laserfiche WebLink

Home Browse Search

�� SS APPLICATION FOR PERMIT i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION � P 0 BOX 2009, STOCKTON, CA 95201 (209) 468---44-7-,W-10 EERLIIT UPIRxS 1 YEAR kROM DATE ISUUM (Complete in Triplicate) 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address I Q VII.-C2City S Ck Lot Size/Acreage Owner's Name �' � Address 1032- Phone 0 i Contractor WOf'A�5 Address O &jrl S - SCf License No. Phone $3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ,„�FO.UNDA.T.ION_ AGRICULTURE WELL OTHER WELL PITS/SUMPS ; INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS,. `tSP� l'-e-V"`r2- n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of ,It Casing U DomesticlPrivate P-0 Grayel Pack ❑ Tracy Type.of Casing Specifications /M Public; 1 I1fOther j ❑ Delta Depth of Grout Seal Type of Grout 0 Irrioation Approx. Depth •0 Eastern m Surface Seal Installed by Repair Wprk Done U Type,of Pump H.P. State Work Done O ✓�� 3 Well Dev:ruction O We11..0iaMeter Sealing Material i;Depth tr Q r Depth Filler Material i Depth / STYPE OF;SEPTIC WORK; NEW INSTALLATION M REPAIR/ADOITION lrl DESTRUCTION CI (No septic system permitted if public sewer is , ! II 1 . ..i I , + 1. . available within 200 feeLl Installation will serve: Residence_. .Commercial— Other ` Number of living units:-_ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. 0 t Method of Disposal Distance to nearest: Well Foundation Property Line i u LEACHING LINE ❑ No. & Length of lines Total Iengthlaiz6 FILTER BED n Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number a SUMPS L1 Distance to nearest: Well Foundation Property Lina DISPOSAL PONOS ❑ 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: 'A 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 ap call for all required inspections. Complete drawing on reverse side. ; Signed 1 Title: - Date: FOR DEPARTMENT USE ONLY AppiticalloEl Accepted Date Area �ksy�ol �, I a 9,,.�. 1 by (�: 'Date 3� f Final�n:pection by Date Additional Comments. _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SBRVICE3 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 INFO EEE AMOUNTDUEAMOUNT REMiTTEO CASH RECEIVED BY DATE PERMIT NO. + EH 13.71 rREV,tin51 !� 0 06 A EH.1.7a