SU0004747 SSCRPT - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN MAQUIN COUNTY PUBLIC HEALTH MMVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O 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 vork herein described. This application is aside in compliance with San Joaquin County Ordinance No. 4 and 1862and the Rules and Regulations of San Joaquin county Public Health /S.errvic`es., f, Rp City til F_ Job Address _ Lot Size/Acreage '— J( Ma�eNo 31 6 - JF ) Ma 2 Phone XOwnor's Name -,�— Address Contracts Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR i OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEP ANK ER LINES DISPOSAL FLD. PROP. LINE UNDATION AGRIC ELL OTHER WELL PITS/SUMPS \ INTENDED USE TYPE OF WELL P AREA CONSTR UCTIO industrial '!a ❑ Open Bonom ❑ Manteca Dia. of Wall Excavation Die. of Well Casing ❑ Domestic/Privy ❑ Gra ack CJ Tracy Type of Casing_ Specifications P1 Pudic -�fl Odor fl Delta Depth of Grout Seal Type of Grout — 11 I Irrigation _Approx. Depth 11 Eastern Surface Saul Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Piller Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted it public "wet is vailabl*within 200 feet.l Installation will serve: Residence_ Commercial_ Other ._ 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 PKG. TREATMENT PLT. ❑ - Method of Disposal Distance to"areal: Well Foundation Property Line LEACHING LINE ❑ No. g Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lina SEEPAGE PITS 11 Depth Size Number _ SUMPS LI Distance to neerast: Well Foundation Property Lina DISPOSAL PONDS ❑ 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and rules and relf joliorm of the Son Joaquin County _ Homs owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ,any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature cenifiss the following: '9 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's co mpenss- tion laves of California." _ The applicant must call for W required inq»ction&. Complete drawing on reverse side.. 1 ��xignod X Q&u. �l� evA/ y Title: (L W -� Date: \\ FOR DEPARTMENT USE ONLY Application Accepted by � _T�.,� 2 bats Area If PN or Grout Inspection by 4/6 Dais Final Ins t�ioPn'by ` Dere Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stan, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED Ck RECEIVED ey DATE PERMIT NO. NFO CASH . EN 11NIaEV.vmm 12� ©O 0 ' IN 4-211 lb