90-2381 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �� G� P O BOX 2009, STOCKTON, CA 95201 t (209) 468-x3447 PERllIT EXPIR S 1 YEAR- 99M DATE IS5UED (Complete in Triplicate) ,, Application is hereby me4e,to San Joaquin County for a permit to conetruct and/or install the Work herein described. This application is trade 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 - J 1 r City `Sjg� -- Lot Size/Acreage Owner's Name u Address Phone • Contractor + �w Addresst�a E t License No.sTIa__11_j�_' Phone _z TYPE OF WELLIPUMP. NEW WELL Q WELL REPLACEMENT n DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR C1 OTHER p Monitoring Well DISTANCE TO-NEAREST:--SEPTIC TANK--- SEWER LINES'—--M-- - DISPOSAL'FL'D:`---" PROP: LI NE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I:] Industrial--- O-Open'Bottom" � © Manieca+ . Dia,.of Well Excavation Dia. of Well Casing U Domestic/Private 0 Gravel Pack 0 Tracyy Type„of.Casing Specifications M Public it Other © Delta Depth of Grout Seal Type of Grout 0 Irrigation ..w.,Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing'.Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDITION Cl DESTRUCTION Rf INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ _. Commercial Other ebekrD,�n -gePT(C Number of living units: Number of bedrooms t-7'Cl Character of soil to'a depth of 3 feet: _ --- 'p�� l� 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 Total length/size S FILTER BED n Distance to nearest: Well Foundation Property Line r SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 �- I hereby certify that I have prepared this application and that the work will ba 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: "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 applicant must call for all requir in tions. mplete drawing on reverse side: Signed Date: �1 - OR -)ENT USE ONLY c Application Accepted by Date1-b i Area Pit or Grout Inspection by Date Final Inspection by_ ! .r''1, __- Date 3 Additional Comments: - Applicant - Return all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES i` 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 IFEE NFO AMOUNT DUE AMOU T REMITTED GASH DECEIVED BY DATE PERMiT'NO. J y . Eht7-74CREV.ilnS� ��lO �� C7' ` EM;1.25