91-0634 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468--3447 II TIRES Y R ih (Complete in Triplicate) Application is hereby made to Sen Joaquin County for a permit to construct and/or install the vork herein described. This application is made in cotmyliance with San Joaquin County Ordinance No. 549 and 3.662 and the Rules and Regulations of San Joaquin County Public Health Services. i Job Address S3 CAAE A a KE E A D 5 i City 7X A/ Lot Size/Acreage r Owner's Name � T� T2 L-1 C- —5'14`65 Address 5A-4f -- ._ Phone II Contractor F oyn E, 1,4teOP Address 7 Al. ADS r License No. 'S`Y�Y7L, phone TYPE OF WELL/PUMP: I� NEW WELL Cl WELL REPLACEMENT n DESTRUCTION ❑ Out ofd Service Well ❑ PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER 0 Mon itoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSJSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS li 'I L-1 Industrial a Open Bottom 0 Manteca Dia. of Well Excavation Dia, of Well Casing a t U DomesticlPrivate ❑ Gravel Pack C1 Tracy Type of Casing Specificationsl k M Public 1-1 Other ❑ Delta Depth;of-Grout Seat- Type of Grout G Irrigation _iI.Approx. Depth ❑ Eastern Surface Seal installed-by Repair Work Done CJ Type of Pump r- H,P. -- - T t State Work pone_ M Well Destruction O Well Diameter _ Sealing Material i Depth. Depih 'Filler Material i Dept) �I r. TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION ,DESTRUCTION*�3 lNo septic system permitted ifIII public sower is �F." available within 200 feet.) '� W Installation will nerve: Residence_. Commercial Other ` SA.vD P Number of living units; Number of bedroorris -- 1 . Character o1 soil to a depth of 3 feet: t Water tablee depth SEPTIC TANK. ❑ TVpe/Mfg C� �— Capacity /60 No. Compartments PKG. TREATMENT PLT. a Method of Disposal Distance to nearest: Well AZA Foundation Property Line LEACHING LINE 0 No. $ Length of lines Total length/size FILTER BED n Distance to nearest: Wall Foundation Property Line II I SEEPAGE PITS i I depth Si se Number SUMPS Ll Di`stanoe tti II nearest: Well Foundation Property Line DISPOSAL PONDS I hereby canify 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 i Home owner Or licensed agent'ssignature certifies the following: "I canify that in the performance of the work for which this permii�is issued, I shall not f 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 t'at in the performance of the work for which this permit is issued, I shall employ to workman's compensa- tion laws of California." y persons subject i a The applicant must call for all ragwred inspections, Complete drawing on reverse side. iI Signed Title: ,h Date: OR DEPARTMENT USE ONLY II Application Accepted by Date T 0 li Pit or Grout Incl»ciion.by `. I� ` >�, pate Final Inspection b IP c _y p Y Data r/ Additional Comments: A77T/aG#-Zf lAPplicant - Return all co lee to: - _ � P SAN JOAQUIN COUNTY PUEILIG HEALTH SERVICES t ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 I FEEi +. INFO AMOUNT DUE AMOUNT REMITTED CK DATE BY RECEIVED CASH PERMIT N0. EH 1 .24 IREV.i/x 51 Ip' 'I CH 141-� -o-� �a� q68 L1 _3a��r `t/�bo