91-1075 - 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 IT EXPIRES-1 YEAR PROM 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. Thie application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County/Public Health Services. ,Q Job Address 1 --3 �,,... � ,.a,.77`– - /YQ.� _ Cityc oCIVLot Site/Acreage 00 Owner's Name Address d T S y Phone L%f4 Centractor ✓ r%/1Q�1 s i 6 _ Address e o �� OtJ License No. 1�7�aZ� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER I�6 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE.C$apQ/y,f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial 0 Open Bottom ❑ Manteca Dia. of W.. Excavation Dia. of Well Casing U Domestic/Private 0 Gravel Pack C1 Tracy Type of Casing SpecificationsG7 M Public I:1 Other CO Delta Depth of Grout Seal Type of Grout dE ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material A Depth Oepth eq Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION Cl DESTRUCTION G (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial, Other Vr 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 M PKG. TREATMENT PLT. El Method of Disposal I' y Distance to nearest: Welt Foundation Property Line 1� t� LEACHING LINE Cl No. b Length of lines Total length/size a FILTER BED IM 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 ❑ 1 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 or sub-contracting signature certifies the following: I canify 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 ust 11 fgf all ired inspec s. omplete drawing on rev rse side. Sign Titl Date: FOR DEPA T ENT USE ONLY J , Application Accepted by Date Area Pit or Grout Inspection by Date ` Final Inspection by Dat Additional Comments. Applicant – Return all copies to: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O B.GX 2009, STOCKTON, CA 95201 INEO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO.