92-3644 - Laserfiche WebLink

Home Browse Search

I APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PA Y jWt P O BOX 2009, STOCKTON, CA 95201R Ivr (209) 468-3447 's t'10V Q 3 1992 (Complete in Triplicate) Pi_�R��1.�0�PUIP'rC01, C.},Mq1 � ! 'J.A1.7" J�ITY Application is here made.to San Joaquin Count for nEi qiF:At-. -' c"r -" pp by y permit to construct and/or install. the vor�"her`ei I deac.rifie�d!f+�gmjn application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and He�&Qi-tUton'a[4V,010/v Joaquin County Public Health Services. Job Address., Q S" -� City Lot Size/Acreage Owner's Name S .� Address Phone cam. � Contract Addres =Sapp se NoAl�a F�PZ—Phon 12W TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well M :,.PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. UNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Indrial C1Open Bottoms ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omastic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout CI Irrigation __ Approx. Depth ❑ Eastern ` Surface Saul Installed by Repair Work Done K Type of Pump`/�-rei� — H.P, � __ State Work Done Well Destruction 0 Well Diameter Sealing Material i Depth Depth Filler Material fe Depth TYPE OF SEPTIC WORK: NEW"INSTALLATION D REPAIR/ADDITION 0 DESTRUCTION G (No septic system permitted if public sewer is FAN available within 200 feet.) a "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. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT,C1 Method of Disposal .-.-Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size t FILTER BED n Distance to nearest: Wall Foundation Property Line SEEPAGE PITS 11 Depth - t Size Number SUMPS Ll�, Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 l i rules and regulations of the San Joaquin County Home 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 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: "I Certify that in the performance of the work for which this permit is issued, I shall employ persons subject c6 Yvorkman's compensa- tion laws of California." The applicant must C `required inspect' ns. Complete drawing on ►ev a side. Signed X _ �y� Title: -Dated` Z� _FOR DEPARTMENT USE ONLY .` Application Accepted by Date A ""Area Pit or Grout Inspection by Date Final Inspection by Date l D Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 B 2009, STOCKTON, CA 95201 FEE INFO AMOU`NNTDUE AM�/O'U�N-�T REMITTED CK RECEIVED BY DATE PERMIT'N'O.. EM 13-24 IREV.I/x 5) / � #S% `r�) 4c7- E+r i4.2e