90-1422 - Laserfiche WebLink

Home Browse Search

9 ' t APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1.601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR PROM-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. Job Address ss 'S y 9 j .ST�e�r'7~ City L3�NTA Lot Size/Acreage";%/ d9 cfe' I Owner's Name mR•�� Mt70 Address p 0, Do '� iSA#rA CA R.S,3o Phone941-2 3ihrr A�irCL C04P•Address a a6ainrd -T RAV1 CrrLicenb v4 cq i Contractor AT '� License No. SS 4!9'1'9 Phone 9'/6-638-7 '746 I TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER O Monitoring ell DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES 411� DISPOSAL FLD.`2 0 ' PROP. LINE -"1 4 FOUNDATION ^, Y AGRICULTURE WELL -d&-- OTHER WELL--k&— PITS/SUMPS A/4 MTE40ED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F] Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation ;INCA Dia. of Well Casing 11 Domestic/Private IX Gravel Peck 0 Tracy Type of Casing SGA47JY1_ ` !10 l'V�- Specifications Cl Public I 1-1 Other F1 Delta Depth of Grout Seal h 10 h-:' Type of Grout AL16477 CL "BNy"' I I Irtigation _.Approx, Depth t I Eastern Surface Seal Installed by VKJ7`/'*r"T 40A;�•NL CC P_ r1 Repair Work Done U Type of Pump H.P. State Work Done v Well Destruction ❑ Well Diameter 42V Sealing Material & Depth , 11 Depth 2 (s rwr Filler Material & Depth .� TYPE OF i SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is I available within 200 feet.) t 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, Cl Methq�gf'pi�osCal�� , I Distance to nearest: Well Foundation Property Li F Erna !fin RECRut W HE LEACHING LINE 0 No. & Length of lines Total length/size I It A rIt 1qqM10111 U FILTER BED ❑ Distance to nearest: Well Foundation Propert Line I� SXN JOAQUIN CO!NZ- SEEPAGE PITS 11 Depth Size NumbejrSERVICES Flo IIr.0,*q SUMPS I LI Distance to nearest: Well Foundation Property Line b'ON i 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 certifies the following; "I certify that in the performance of the work for which this permit is issued, I shall not i 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." The applican ust call for all r d inspections. Complete drawing on reverse side. Signed X_I_� "'�'� % R �`�''"� Title: PniNc,�Pi9L # !! t' if7— Date: CALr nNiA 6evt T OY7/9 FOR DEPARTMENT USE ONLY �,v/� !,l�1 C� / Application Accepted by __ _ lxe, _ Date �J �Q area y 3 Pit Grou inspection by tom.-- Date - IZ' 9 Final Inspection by �'Z-• ,PSS 6l^- Date Additional Comments: i 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 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. j r E 13-24{REV.i I 1 EHN 14.2e j 3_<_� � 7