80-1886 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ,1 v SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (249)46$-3420 P O BOR 2009, STOCKTON, CA 95201 PEMIT 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 1l,,,__ Job Address (A c C City Lot Size/Acreage Owner's Name /7 YV U li )F=19 ' Address f fr (,O kf Phone Contractor L&MOV ) r Address p lq'A rZa kQ - 41P IT—License No. Phone TYPE OF WELL/PUMP: 17EW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION)d� SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK F'P6 SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Ik INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ✓ 171 industrial "'Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing�rl'rG�G - -__ __ Specifications r I"I Public i-1 Other ❑ Delta Depth of Grout Seal Typea Groutr�/kry4- I Irrigation �Q Approx, Depth I Eastern S rface Seal Installed by g-. �r I ti* Gt Repair Work Done L] Type of Pump :5 e' • H.P. State Work Done J Well Destruction O Well Diameter Sealing !Material & Depth Depth Piller Material Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION ( I DESTRUCTION i I 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. ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED LI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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, z 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 n t employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatur certifies the fotlowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa Non laws of California." The applicant must ,,,,caallll}}}ffor all required inspections. Complete drawing on reverse side. Signed �� / /1f 4 ZL 4 eQ--!1..,.._ Title: Y S. Date: �a FOR DEPARTMENT USE ONLY Ap:`Groul cati cepted by SldNsd,�, y_,,,•_,,,_ Date 7 Area t 5 Pit In cNon by 1 Vt f - --- Date Z� Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 952 FEE INFO AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERM17'NO, ' r • EH ti. (REV.t�n51 cl <0Vt� - �25 -to cI D- 1