SU0004646 - Laserfiche WebLink

Home Browse Search

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 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. 5 9 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Addre s `�' /` ' City Lot Size/Acreage r ,Owner's Nametiross qi LAt Phone Contfaclor Addres"' Z7 License No. I lei 1 23, Phon CJ TYPE OF WELL/PUMP: NE15 WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/'SUMPS _ I ENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing r Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_._ Specifications I'I Public 1-1 Other rl Delta Depth of Grout Seal Type of Grout I I Irrigation _ Approx. De h I IE Surface Seal Installed by Repair Work Done 0-1, Type of Pump v- Q H.P. S State Work Done ^ Well Destruction O Well Diameter Sealing Material i Depth 1 Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units; Numbr of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. 6 Length of lines Total length/size FILTER BED CI Distance to nearest: 1 undation Property Line SEEPAGE PITS 11 Depth Size Number r 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 1i nt'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 ion in such nner as to become w to workman's compensation laws of California." Contractor's hiring or sub contracting signature candles the o*owing: "I ce fY that in perfor nc of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws f Califo nla." The ap scant m t c r all r c s. C plete drawing o ev siN&41(1 Signed d Title: Date: Zo FOR DEPARTMENT USE ONLY 61 / Application Accepted by k,t,11 �A � D,�.,,�, Date Area 0 'v Pit or Grout Inspection by Date Final Inspection by I- Date Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Boz 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED By DATE PERMIT NO. EM17.34(REV.,,n 51 f4,v EH 14.2E 7pp � �' �'