SU0003868 - Laserfiche WebLink

Home Browse Search

>* APPLICATION FOR PERMIT a, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES # ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 SEP 9 1991 (209) 468-3447 ENVIRONMENTAL HEALTH PERMIT EMIRES 1 YEAR IFROM DATE ISSWU PER T/:i LR4l(.t_5 (Complete in Triplicate) Application is hereby made to San Joaquin County for s permit to construct and/or install the work herein described. This application is sable in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. RJ 7 Job Address �?&00 •� � ' "` City bid- �I'Ot Bite/Acreage Owner's Name 11 - `Y<-r/—Address - -ti�-V � Phone c 2 ' � r� Contractor _ Address lea ga"s r: 93Cl-`Cense No. �..+ y_� - Phone ' l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ Out ❑ PUMP INSTALLATION & ' SYSTEM REPAIR Lg� 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 n Industrial [5-0 pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 'A.Domostid/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public 1:1 Other O Delta Depth of Grout Seal Type of Grout r ` ❑ Ifngation Approx. Depth ❑ Eastern /Surface Soul Installed by Repair Work Done (fig-Type of Pump H.P. ICY"'- State Work Done Well Destruction O Well Diameter Sealing Material A Depth C Depth Filler Material A Depth n TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION Cl DESTRUCTION M (No septic system permitted it public sewer is available within 200 feel.l Installation will "No: Residence _ Commercial _ Other Number of living units: _ Number of bedrooms n Character of soN to a depth of 3 feet: Water table depth 'V SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. g Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Lim DISPOSAL PONDS ❑ I hereby comity that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rues and regulations of the San Joaquin County Home owner or licensed agent's signature cenlfies 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 of sub-contracting signature cortiflas 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 compensa. tion laws of California." The applicant mu c f all required insiMections. Complete drawing on reverse side. p Signed x Q - �' Title: �l-4- Date: '21- /ey / DEPARTMENT USE ONLY Application Accepted by f/_/_7JDJAv Date Area G�+///�/191Pit or Grout Inspection by ate Final Inspection by Date Additional Comments. / - Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT NO. INFO ff.CA�SH '/r . EM 13J41RE ��.lV.r/rr 6r H� OBJ i. ✓ .7t �` II ��•• fM A-211 1