91-3172 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 NO P O BO%` 2009, STOCgTON, CA 95201 !PERMIT EXPIRES 1 YEAR FROM DATE ISSUED =�Z (Complete in Triplicate) r 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., f air C Oil -f Job Address 1 r7 �J �]� +O 1 l\/-s,', City l aot Size/Acreage Y� f S �/ L�� Phone, r Owner's Name ` Address p Contract ddress License No. Phone TYPE OF WELL/PUMP. NEW W LL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 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 CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing CI Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications !'I Public IJ Other f-I Delta Depth of Grout Seal Type of Grout I I frrigalion —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Dona ❑ Type of Pump H.P. State Work Done w Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Materiel 8 Depth l] TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is vailable within 206 feet.) Installation will serve: Residence_ Commercial_ Other t 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 t l nearest: Well Foundation Property Line LEACHING LINE ❑. No. & Length of lines Total length/size FILTER BED ❑ Distance t0:nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number- SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 11.1 I hereby certify that I have prepared this tipplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sen Joaquin€County Home owner or licensed agent's signaturalcertifies the following: "i cattily 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 taws 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." 1 II{{The applicant ust call for all required inspections. Complete drawing on reverse side. I a, �(4Signed X Title: tC R:. Date: �� f OR DEPARTMENT USE ONLY ` s1 Application Accepted by Date ! rt^x_17 ` ._ Area Pit or Grout Inspection y Date� Final Inspection by Data Additional Comments: O 7' �` 3 TfT Q 7�`K C uAg 4zk �- 1 i Applicant - Return al Pigs to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE 1 INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. EH13-24IREV.Iinsl r DAv[ 1. En 14.2e