SU0013396 - 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 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 work herein described. This application is made in ccnpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San .Joaquin County Public Health Services. � A .�-� 9� /I Job Address z City Lot Size/Acreage Owner's Name 11,/V �0 �.�L,� Address Phone 07-7?73/ Contractor 4l s Qin LAddress��JD�,�I l License No. � 77 Phone _ TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT Cl DESTRUCTION Ll Out of Service Well D PUMP INSTALLATION O SYSTEM REPAIR Ll OTHER O Monitoring Well O 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 Q , ( I Industrial U Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing 1� r I Domestic/Private Cl Gravel Pack U Tracy Type of CasingSpecifications I'I Puhlic Cl Other [l Delta Depth of Grout Seal _ Type of Grout V) I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by napair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth �. Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIO INo septic system permitted if public sewer is available within 200 feet.) 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. 8 Length of lines _._ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEFPAGE PITS 11 Depth Size Number SUMPS LI 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 San Joaquin County [tome 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 shell 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 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 Calif z/�tis.,, The applicant utR call for all_qliquired ingaictions. Complete drawing on rave side �1CignedTitle: Date: Z— FOR DEPARTMENT USE ONLY q 4 Application Accepted by � - ,p L L"'S q Date ` -'),1 1 L Area E ` Pit or Grout Inspection by \ Date Final Inspection by Date Additional Comments: �C-"'�K5 C P 5�f a Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. FN rl z,nary r„tit �-al FN 14]!