92-0967 - Laserfiche WebLink

Home Browse Search

x0m r � APPL I CAT I ON FOR PERid I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 'p PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7 e 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. / r .,,,,/,Job Address City Lot Size/Acreage �g��AlzA_J Owner's Name IV" QAddress f ' PhoneCID ' " I . /�o ,��7r3.r r z zz 10 ` 3b�- S Contract Address License No. Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Nell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE W FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F) industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C] Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications ['I Public is Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal installed by Repair Work Done 0 Type of Pump, H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION E IREPAIR/ DDITION 1 DESTRUCTION [ 11No septic system permitted if public sewer is available within 200 feet.) Installation will serve: 'Residence Z�_ Commercial Other F , Number of living units: Z Number of edraom /7 Character of soil to a depth of 3 feet: Water table depth V SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r r le LEACHING LINE L1 No. A Length of lines _ ! '� Q Tial length/size FILTER BED Distance to nearest, Well 16D 'F Foundation Property Line t SEEPAGE PITS ti Depth Size Number SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ a ' 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 Horne owner or licensed agent's signature certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of subcontracting signature I 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 applic ust call f r iced inspections. Complete drawing on rev er sifie„ Signed X Title: 1 _ Date:all OR DEPARTMENT USE ONLY Application Accepted by Dpte Area .�r ` ` Pit or Grout Inspection by Date Final Insp�tid by� Q— Date ` Additional Comments: �� Applicant - Return all copies to: Saw Joaquin County Public Health a Services, Environmental Health Permit/Services `� 1601 E. Hazelton Ave.. F 0 Box 2009, Stockton,/CA 95201 %? FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By'\ r,'"'� GATE PERMIT'NO. s,P �a n� + fN 13-21 IREV.t/M5F EH jci- 1