90-3346 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTB SERVICES ENVIRONMUTAL HEALTH DIVISION ' I 1 601 E. HAZELTON AVE. , PHONE (209)468--3420 NJ P O BOX 2009, STOCHTON, CA 95201 K/OZ 47- 506 P,EaKIT EXPIRES I XEAR f aQM DA TS I Ss§UED d� (Complete in Triplicate) �a Application is hereby made to S&c Joaquin County for a permit to construct and/or Install the work herein described. This application is aade inllcamgliance with San JoKuln County Ordinance No. 549 and 1862 and the Rules e.nd Regu?Ations of San Joaquin County Public Health Services. /S�vid of �2Q ,f/�RDI�EE Ex G aGIl.I�iN(j I Job Address City /ODV Lot $1ze1Acreage -ZZD_ *A9' v1 0wnee's NameRAI7' rldt2Gss . Phone Contractor B_ _� �� _- — _ Address QST License ho..]�9 Phone s 6 TYPE OF WELL/11JMP: N' `J NEW WELL WELL REPLACEMENT Ll DESTRUCTION Out of Service Nell ❑ MP NEW C �/� Cl SYSTEM REPAIR © � OTHER 0 Konitoring Well � t ! DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES DISPOSAL. FLD._ PROP, LINE FOUNDATION 1211—D ZAGRICULTURE WELL OTHER WELI._ PITS/SUMPS INTENDED USE I�TYPE OF WfLL PR09LEM AREA CONSTRUCTION SPECIFfCATIONS Industrial V Open ottom C Manteca YDia, of Wall Excavation — _/rf Ala. of Well Casing [:1 D stir/Private Cl vel Pack 0 Tracy Type of Casing Specifications .- i'I Publ' other n Delta Depth of Grout Seal yCR 6CR1�EJ XTYpe of Grout 7-s.9�.r I i I trrlgarron II _Approlt, Depth I I Eastern Surface Seal Installed by G"En-i4=�T 4r7 Repair Work L]1�!p Tyet pump H P, State Work DonsWell Dest ion 0s ,�[8ealing Naterial & Depth Pilxas Material & Depth TYPE Of SEPTIC WORK: NEW INSTALLATION i I REPAiRIADDITION I ! DESTRUCTION t I (No septic system permitted if pubtic sewer is available within 200 lest.1 installation will serve- P.I�idence_._„ Commercial Other -- Number of living units: �� Number of bedrooms Character of soil to a daptM of 3 fest; Water table depth SEPTIC TANK 13 Type/Mfg Capacity�� No, Conn2onftento PKG, TREATMENT PLT, Cl Method of Disposal Distance to nearest: Well`� Foundation_ Property Line I LEACHING LINE 0 No. & Length of lines Total *nglh/size FILTER BED 1-1 Distance to nearest; Well Foundation _ Property Line SEEPAGE PIT5 I 1 Depth Site_, Number SUMPS 0 Distance to nearest: Well Foundation _ Property Lina DISPOSAL PONDS ❑ . I hereby certify that! hove prepared this application and that the work will be dorsa in accordance with San Joaquin county ordinances, state laws, end rules and reguialiaAe of the Sari Joaquin County Home owner or licensed agent's signature certitiss the following: "I certify that in the Darfprmence of the work for which this prartnit is issued, I shall not employ any person in such manner as t0 becoms aub*t to workmen's compensation laws of California." ContraCtora hiring or suis-contracting signature Certifies the following: 'I Certify that in the performance of the week for whish this p6rmit is;rived, i shall employ persona subject to workman's compenes- tion laws of Caiifornls.' The applicant must call for all rsquir tn"W.Vigna. Complete drawing on reverse side. y / Signed I� Title: ��20.T��TG��'�2 /-Z //r 90 \ � II Dale: .` ,I FO DEPARTMENT USE ONLY s Application Accepted by 'I Date- . _5 !47 Area I VPit or Grout Inspection by I� Date _ Final Inspection by rc Data ' Additional Comments; Applicant - Return &U copies to, Sen ,Toaquin County Public Health 86tvices, Raviromwatal Health Pasmit/Services 1641 P. Hazelton Ave., P 0 Se% 2009, Stockton, CA 45201 Fig AMOUNT OV9 AMOUNT REMITTED CK RECiiVED By DATE f FRMiT'Nt1. INFO CASH �x r 1114 EMt M24 iRLV,+i ti e1 S I,e 00S !Z 14-a0 ?�� i 06/r/so 1/b (� !O-33 W0J