SU0004188 - Laserfiche WebLink

Home Browse Search

I APPLICATION FOR PERMIT i 0, RL � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �I ENVIRONMENTAL HEALTH DIVISION NOVi 5 IM P 0 BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH (209) 468-3447 PERMIT/SERVICES (Complete in Triplicate) �M IN Application Is hereby tasde,to San Joaquin County for a permit to construct and/or install the work herein described. This application In made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules aad Regulations of San Joaquin County Public Health Services, If Job Address.�, L� j "� City t Site/Acreage I� 1 I� Owner's Name Address Phone Contractor Address TLicense No. V46.2- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well Cl PUMP INSTALLATION 0 SYSTEM REPAIR OTHER ❑ Monitoring 41e11 ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS { n Industrial 0 Open Bottom ❑ Manteca Dia, of Weil Excavation Dia. of Well Casing ' vDomestic/Private ❑ Gravel Pack 13 Tracy Type of Casing Specifications IM { M Public Ia Other ❑ Delta Depth of Grout Seat Type of Grout l CJ Irrigation Approx-DepthC 0 Eastern Surface Saul Installed by it Repair Work pone Type ol,Pump_ H.P. State Work Dona A- L&tAe4LAZ!nl� Well Destruction O Welt Diameter Sealing Material i Depth i, Depth Filler Material i Depth TYPE OF SEPTIC WORK: .NEW INSTALLATION 0 REPAIR/ADDITION Ll DESTRUCTION 0 (No septic system permitted it hpublic sewer is available within 200 feet.) 5. Installation will serve: Residence_ Commercial ._..Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i Water table depth w SEPTIC TANK O Type/Mfg Capacity No. Compartments li PKG. TREATMENT PLT. C) Method of Disposal �M Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size IM r t FILTER BED n Distance to nearest:, Welt Foundation Property Line SEEPAGE PITS I I Depth Size Number II SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 Sari Joaquin County !I1 Home owner or licensed agent's signature certifies the following: "I certify that in the performance,of the work for which this permit 1s 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: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compsnsa- tion laws of California." ; l li The applicant must call r all required i spections. Complete drawing on reverse side: I� �_. q Signed X . Title: Date: FOR DEPARTMENT USE ONLY Application Accepted byArll_ 4��l Date F` Area / +, Pit or Grout Inspection by Date Final Inspection by II' Data // •��° •S ir I. -- - Additional Comments: t Applicant Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES ! 445 H SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 65201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PEFIMil'NO. + . EH 14-20 iRIY. firerr .� 1l C 1�0 114-20 �� ' ! r / �� ,