92-3054 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PEMIT .EMIRES- 3. YEAR (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 I Joaquin County Public Health Services. Job Address I !)• CityfiMP 0 Lot Size/Acreage Owner's NameT1 Address Phone 33T f a ,�y `� Zc)9 ` ContractoEAA1 O.S r 3 am/ J Address g-5-.3 " ti co �I tense No. Phone :2562—_20 iR TYPE OF WELLIPUMP: NEW WELL ®�, WELL REPLACEMENT ❑ DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATIOI SYSTEM REPAIR ❑ OTHER p Monitoring Well (7 DISTANCE TO NEAREST:-SEPTIC TANK /G[S` SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial !�n Bottom © Manteca Dia, of Well Excavation Dia. of Well Casing k4*105mestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications M Public 1-1 Other ❑ Delta Depth"of Grout Seat JrO+' Type of Grout ` CI Irrigation ____Approx. Depth C1 Eastern Surface Seal Installed by -n Repair Work Done U Type.of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth k Depth Filler Material Z Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION LT DESTRUCTION Ci INo septic system permitted if pubtic sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other y Number of living units: Number-of bedrooms k Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT,0 Method of Disposal Distance to nearest: --Well ____-- Foundation Property Line ' LEACHING LINE t ❑ No. b Length of lines Total length/size I FILTER BED t _ E_) Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size f _ Number - SUMPS CI 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 R employ any person in such manner as to become subject to workman's compensation laws of Caldornia." Contractor's hiring or sub-contracting signature certifies the fallowing: "I certify that in the performance of the work tion laws of California." I Tor which this permit is issued, I shall employ persons subject to workman's compensa- tion 4 The applicant myjkL call If I required inspections. Complete drawing on reverse side. 1. Signed Tiftle: Date:. F IM ENT USE ONLY Application Accepted by QDate Area Pit or Grout Inspection by Oats L d anal Inspection by Date Additional Comments: P Applicant - Return all copies to: SAN JOAQUIN COUNTYPUBLICHEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES [A�" 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 l FEE AMOUNT DUE AMOUNT REMIT-rEo CK RECE1vto BY DATE PERMIT'NO, INFO 9 EH 13-24 1 PEV.I)H 5)W A EH A-211