92-3171 - Laserfiche WebLink

Home Browse Search

.� rr APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 r PERMIT EXPIRES I YEAR FROM DATE SU (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or inatoll'the work herein described. This application is made in compliance frith San Joaquin County Ordinance Ifo. 549 and 1962 and the Rules and Regulations of San Joaquin Count cPublic Health Service4. Job Address 6 C S+eCity Lot Size/Acreage no iNamec, � Address Phone, dress Z ' ^ License No. Phone't 3 4~ ZI TYPE OF ELPUMP: NEW L ❑ WELL REPLAC ENT [1 DESTRUCTION'❑ Out of Service Well ❑ WU PUMP INSTALLATION SYSTEM REPAIR 0 OTHER D Monitoring He11 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i A0 1 duatrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing tl1estic/Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications 11 Public 1"1 Other n Delta—Depth-of-Grout Seal Type Grout I I Irrigation _Approx. De I Eastam 1� �5yQace Seal Instaflp by Repan-Work Done 0 Type of Pump H.P. _. je --' _ State Work 0 Wall Destruction ❑ Well Diameter/ $soling•Material i Depth Depth ��lC — Filler Material i Depths' TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No sepfic system permitted if public sewer is *.� aviiiable within 200 last.) Anstallation will serve: Residence_ Commercial.— Other p -..,„...r.,,�- Number of living units; Number of bedrooms �_ r, Character of sort to a depth-of-3-foot: Water-table.depth SEPTIC TANK . 0 Typs/Mfg Capacity—. No. Compartm'nts PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Lina 11< LEACHING LINE 0 No. b Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depfh 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 be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Countym Hoe owner or licensed agent's signature certifies the following: "t certify that in the performance of the work for which this permit is issued, l shall no 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-t tion laws of California." The appticon"ust call q I required inspections. Complete drawing on r arse side. Signed X /��d �p Title: Date: i FO DEPARTMENT USE ONLY Applicetion Acceptrid bye�w� �• -•_M..-Date 5 L Area Pit or Grout Inspection by Date Final Inspection by &WeDate "� J Additional Comments: I Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health'Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO.�p GASH . EH13.24[REV.111%51 EH 111.26 TTT f ,