91-0922 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT i SAN JOAQUIN COUNTY PU13LIC HEALTH SERVICES i' ENVIRONMENTAL HEALTH DIVISION I� 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 �• RTMIT EXPIRES 1 YEAR_FROM DAA, 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 Hea;i1tl ervices. AI - �J; / Job Address 5— 5- ` - City�6A "0A"' Lot Size/Acreage F ,� t.. Owner's Name d�m •.Address �' ` _" `r'�, _ -Phone--_-.--. I p� Contractor r/ Address Kv l-l 'ALicense No. Phoni? � TYPE OF WELKAUMP. �I` NEW WELL ❑ WELL REPLACEMEN DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ❑ f DISTANCE TO NEAREST: SE'TIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I n Industrial ❑ Ogen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I1 Domestic/Private ❑ GravelPack ❑ Tracy Type of Casing. Specifications i'1 Public Cl Ot`her f- 1 Delta Depth of Grout Seal Type of Grout I I Irrigation ��}Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done ❑ Type-of Pump H.P. State Work Done_ s 6 Well Destruction ❑ Welf Diameter Sealing Materiel & Depth .,. Depth Filler Material d Depth TYPE 01,SIPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I } DESTRUCTION INo septic system permitted if public sewer is I` available within 200 fest.l Installation will serve: Residence Commercial_ Other +' Number of living units: ib Number of bedrooms �! Character of soil to a depth of"3 feet: _1 � Water table depth SEPTIC TANK. ❑ TVVp a/Mfg Ca acit I P y Y - No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation-,Property Line LEACHING LINE Cl No. & Length of lines Total length/sire FILTER BED ❑. Distance to nearest: Well Foundation Property Line w SEEPAGE PITS 11 Depth Size Number , SUMPS Ll Distance to nearest: Well Foundation Pro 3 perty Line DISPOSAL PONDS ❑ ,I�� 1 I hereby certify that I have prepaad this application and that the work will be done in accordance with San Joaquin county ordinances, sta , rules and regulations of the San'Joaquin County te lawsand employ any person in such manner as to become subject to workman's compensation laws of 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 California."Contractor's hiring or sub-contracting signature certifies the following: "I certify tliat 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." ill , I i The applicant must all for `uir d inspections. Complete drawing on reverse side. t Signed X�� — Title: Date: I` FOR DEPARTMENT USE ONL Application Accepted by 10 ;Z�, 3 � � Date rea Pit or Grout Inspection by I Date Final Inap ction b „ :Dated Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental-Health Permit/Services I. 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE i INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO, CASNEH 13-24(REV.tins) :174 G (/� ( ..��1/y��/EH i�-2B X, l 1 �t 1 0 N'a ...yam`-•=r I� E