92-3524 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES , ENV I RONMENTTTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 _ P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the stork 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. .lob Address � ``S� j ,VC'K" RJ �f Cify"` ' y�t size/Acreage Owner's NameAdir Address f Phone ' 4 Contractor Address ^ 7"�� License No, Pho,3C Jb�7 TYPE OF WELLIPUMP: NEW WELL ❑ WELL KEPLACEIVIENT,1711 -- DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 ` � OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES %,.DISPQSAL-FLD. - PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS " E--— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n C'D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing C7 Domestic/Private ❑ Gravel Pack ❑ Tracy "� Type of Casing Specifications :. Il Public 171 Other ""�F1 Delta Depth-of Grout Seal Type of Grout I I Irrigation 3.Approx. Depth 1 I.Eastern, Surface Seal Installed by k Repair Work pone D Typa of.Pump • H.P. State Work Done Well Destruction " O Well D+ameter Sealing Material i Depth' Depth), Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTA-LLA'TiON I 1 REPAIR/ADDITION I DESTRUCTION i I INo septic_,system permitted if public sewer'is ' e available within 200 feet.) Y- j Installation will serve: Residence_ Commercial_ Other t _ F_ Number of living units: •=Number of bedrooms Character of soil tp to depth of 3 feet:, it f Water table depth SEPTIC TANK. ❑ k�TypPCapacity No. Compartments -� PKG. TREATMENT PLT.❑ x u Method of Disposal l� Distance to nearest: Well Foundation Propertyine, LEACHING LINE No. & Length of linea l s Total length/size-. K E FILTER BED Cl Distance to nearest: Well�/ _ Foundatian`��,Property-Line_ __ r u r SEEPAGE PITS Depth Size �� - J Number47 SUMPS LI Distance to naarosic Well.. Foundation'! Property Line /Q 'DISPOSAL PONDS ❑ _ 1 hereby certify that I have prepared this�licotion 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 1 A Homeowner or licensed ayent,s-klgneture certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not t employ any person in such r�nennar as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature z eertifies 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- ' fion taws of California." ,� t The applican call fpr ell requ' do Complete drawing on reverse side. Signed Title: _ -- _----- __- Date: l FOR DEPARTMENT USE ONLY Application Accepted by DateA== Area Pit Grout Inspection Data L� r� pee Finsl In ction by{ Date / / Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health r$ermit/5ervices� 1 445 N-.San Joaquin, P 0 Box 2009, Stkn ,,QA-95201 FEE INFO AMOUNT Dt1E AMOGi1TMtT RETEQY . CASH RECEIVED BY DATE PERMIT'N0. . EH tlt4 erIEV.rreaE �p y` em 461!6