90-2100 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 goor J08 90-1356-07 a, R)M 1:C EXP I RES 1 YEAR_FRQM DATE ISSUED M 4S77S4?- (Complete in Triplicate) ST`a 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. 549 and 1862 and the Rules and Regulati6hs of San Joaquin County Public Health Services. Job Address /81:30 46 CJ'tyy :577 _ city f Lot Size/Acreage ' �$WL Ct+5.vS4T+�+0 9r- GernB-'77h'uY� G a Owner's Name - Address Phone -9`Z�000 t ContsactorSL7Lht X /N r9Rddress0Z� i�� /llYlllZlz� $Ie License No.�Z',�$ _ Phone kg—(s TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER . I 2 S7`i 80� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. r-OL";bt FOUNDATION AGRICULTURE WELL OTHER WELL �G INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , F7 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation -1114 M WAII raqpng - E Domestic/Private ❑ Gravel Pack CJ Tracy Type of Casing �s 1211�(bs I"I Public fa Other Ll Delta Depth of Grout Seal Tgp�ofi 8raet- ' C 1 I Irrigation Approx. Depth i I Eastern Surface Seal Installed by lr 1LU6!f f Repair Work Done U Type of Pump H,P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I f DESTRUCTION I I (No septic system permitted it publiclsewer 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. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Welt Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t 4 SEEPAGE PITS It Depth Size Number SUMPS L3 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 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, 1 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 to workman's compensa- tion laws of California." c The applicant st call for allr .red inspections. Complete drawing on reverse side. Signed X Title: Date: OR DEPARTMENT USE ONLY M Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additions! Comments: � , �� C�(.r� Z__C�UY►�,rJ(ptR.t9 c.�t�yit,�___, ��, __1/�'a :: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services " 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. e . [:H 13.24 IREv.t/M E H 134.20 o-14 C r