92-3569 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 41 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ' 445 N SAN JOAQUIN, PHONE (209)468-3420 ,L tea .. 3,S7Z-r7z P O BOX 2009, STOCKTON, CA 95201 C19-6["5 -ry TDc�Ff�- PERMIT 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 vork 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 �ZZp ,Soy ��/� /�V,655- City )2-/)o d^-/ Lot Size/Acreage Owner's Name 427'y bF R/1:f07'J Address 519-en IS cY� Phone N5272— Z/Ob Contract I/-E� 2Address_111'-�2.S E. MYt2?Zl9 5� License No:-�Z2-68 Phone WO-1346- TYPE g^r< 4TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - 2 gpytt Jb9 FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z01 -d- ypl C1 Industrial O Open Bottom O Manteca Dia. of Well Excavation Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ -Spssitications 47-716 I'1 Public Cl other n Delta Depth of Grout Seal .ape-offarevt- "&L me F , I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by U`f U,( l� Repair Work Done U Type of Pump H.P. State Work Done_ N' I t Z C Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial_ Other available within 200 feet.) 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. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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, 1 shall not employ any person in such(Wenner 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 applicant st ca-0 for all required inspections. Complete drawing on reverse side. Signed X_%_ �G2J�1 r-�t_ A Title: 1 7— /Q - 2-0 7— Date: ZF D RTMENT USE ONLY Application Accepted by Der Pit or Grout Inspection by Date Final Inspection Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IFEE AMOUNT DUE AMOUNT REMITTED_T?1 K RECEIVED BY 0 E PERMIT'NO. . EM 13-24111EV.1/hal ( .=�" EN 11.26 J