92-3726 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERI[I T 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-MIRES 1 YEAR FROM DATE ISSUED 114 „ A (Complete in Triplicate) �/ .� A Application is hereby sleds to San Joaquin County for a permit to construct and/or instal] the work herein described. This�' application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulatfons of Sari Joaquin County Public Health Services. Q[� Job Address � 3_J�'-'-J / Y- --I� •-h;E City Lot Size/Acreage Owner's Name �6d __ Phone 7 Contrac AddressLicense No. hon aL TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ED Manteca Dia. of Well Excavation Dia. of Well Casing EI Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications i i'1 Public 171 Other ( Delta Depth of Grout Seal Type of Grout I I Irrioalion _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Al Commercial Other Number of living units: -,L— Number of bedrooms Charsaw of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT,0 Method of Disposal � Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth 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 wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any parson 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 California." The applies for all ad Ins tions.IC"omple drawing on re s� 72 Sig 'tle: Date: _T�1 ORD PARTME T USE ONLY117 �r ppiicstion Accepted by -� Data f Area I Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: c)E l C- t 3 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 44545N N San Joaquin P O Box 2009, $tkn, CA 95201FEE INFO OUNT DUE AMOUNT REMITTED CKS CASH RECEIVED BY DATE PERMIT'NO. JF_ . CH 13-21 tRtN.t i h 67 C [C; ` e) / J I ! 172,-1-7FIi 1�•la J r0 [7 Z- i