90-2778 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONNdENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 R FROM DATE LUMM (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 c=Wliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. J � (� of Size/Acreage Job Address Y Owner's Name �_ • Address Phone Conlractor Address l License No. / f Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (:7 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ 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 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private Q Gravel Pack C1 Tracy Type of Casing ___ Specifications M Public I:1 Other 0 Delta Depth of Grout Seal Type of Grout 6 Irfipalion _.Approx. Depth ❑ Eastern Surface Seul Installed by Repair Work Done L] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRlADOITION 0 DESTRUCTION G INo septic system permitted if public sewer is O available within 200 lest.1 Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 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 Cl No. & Length of lines Total length/size FILTER 13ED [1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 at sub-contracting signature certifies the following: '9 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 mus call or all required inspgctions. Complete drawing on reverse side, //� Signed Tide: .�r�' X>)� Date: le' - [7 FO A T USE ONLY Application Accepted by Date 16?11,710rool.Aroa 4�03 3 Pit or Grout Inspection by Date Final Inspection by Data/� �� Additional Comments: Applicant – Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN. P 0 BOX 2009, STOCKTON. CA 95201 FEE INFO AMOUNT DUE AMOUNT AEMiTTED [ASH RECEIVED 6Y DATE PEAM17'NO, . EH 13.1/I>+EY.1/45) A /7 Eli;{•2e