91-1155 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 9.5201 (209) 468-3447 ��tEtuTT IR S ] YEAR SROM DATE SUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or inetall the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regalatione of San Joaquin County Public Health services. /? C� AITL - City - -- Lot Size/Acreage Job Address _.�, 2--0 '). _ Address 4/ 2404-Y-11 d� s 'J _ Phone Owner's Named f ; - - ',------ -------•--g— -- - -- -- ._ Y7 Z`"Pt+one- Contractor--E-L4 . ° Address �! Af1��i`�2 AdE License No. all 0 TYPE OF WELL/PUMP: f NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION LJUut of Service Well PUMP 11,i INSTALLATION C7 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATIONi'�` IAGRICULTURE WELL 'AOTHER WELD Y PITS/SUMPS .:F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f.7 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing Specifications M Public i.l Other ❑ Delta Depth of Grout Seal Type of Grout CJ Irrigation ApproK. Depth D Eastern Surface Saul Installed by Repair Work Done U Type of Pump H,P. State Work Done , Well Destruction D Well pSealing Material & Depth Diameter Depths Filler Material i Depth i TYPE, OF SEPTIC WORK: NEW;INSTALLATION REPAIRlADDtTION L7 DESTRUCTION Cl iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence -Commercial— Other &14 e Number of living units: 4--1 Number of bedrooms !4� Character of soil to a depth of 3 feat: , /=4 y - Water table depth SEPTIC TANK V Typa/Mfg Capacity I b ro C2 No. Compartments PKG. TREATMENT PLT JI� /6, r Method of Disposal Distance to nearest: Well Foundation � Property Line Y V LEACHING LINE No. & Length of lines Total length/size O FILTER BED Cl Distance 4o nearest: Well--�- A Foundation !DB_ - Property Line �N SEEPAGE PITS ! Dojth r T Sixa Z r Number 3 r SUMPS LI Distance to nearest:,. Well #_ Foundation�L Property Line DISPOSAL PONDS C) .11. .1 1 I hereby certify that I have prepe`red 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 x Home owner or licensed agent's'signature certifies the following: "I Certi-Y 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 fotlowing: "I certify that in the porlormence of the work for which this permit is issued, I shall employ persons subject to workman's compensa• tion laws of California." If f— . The applicant must call for all r II�uired inspections, Complete-drawing on re-verse tide. Signed Title: Date: FOR DEPARTMENT USE ONLY S l 7/4) I Application Accepted by Date Area Pit or Grout Inspection by IM Date_.Final Inspection by Data _ ` Additional Comments. - d Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN., P 0 BOX 2009,.STOCKTON, CA 95201 rFEE AMOUNT DUE AMOUNT REMtTTED CA S RECEIVED BY DATE PERMIT NO. INFO `` CA/5iH 01-11 EH 13-24IREV.11951 � EH',/.2e