91-1119 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT /,0).. . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES C.ky ENVIRONMENTAL HEALTH DIVISION NED 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 2EMIT 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 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 _ Z 97-6-6 zlic_x' m ]b_ City 11 Lot Size/Acreage Z� C Owner's Name/4Y 61c [ ^, Address Phone f 7 3 a yY Contractor _�l'7 17 �� Address, `y /] License No37 d r Phone TYPE OF WELL/PUMP: NEW WELPIn WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C� DISTANCE TO NEAREST: SEPTIC TANK fad_ SEWER LINES __ DISPOSAL FLD.-ii-Q9 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 6 ;domestic/Private Gravel Pack ❑ Tracy Type of Casing OYC ,,,,,,,___ Specifications- fr_'3!p'?.._ F) Public El Other 1-1 Delta Depth of Grout Seal - -10D Type of Grout_Ct/rnt�l I i Irrigation -L,0 4 Approx. Depth I I Eastern Surface Seal Installed by—�s2/_`- �iZ,�cTa_ Repair Work Done 0 Type of Pump S�� H.P. __ �,. _ _ State Work Done 4/t- - S TCr6�y Welt Destruction ❑ Well Diameter Sealing Material b Depth Depth Filler Material b Depth TYPE OF SEPTIC WORK: NEW IN I I REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.} 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 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 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, I shall not 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 applicant mus call It r all to ired inspections. Complete drawing on reverse side, Signed Title: _4tn� _ Date: FOR DEPARTMENT USE ONLY 4� j Applica 'on Accepted by r ' Dates/ f ` Area Pit rout epection by _15a Date 1 Final Inspection bye vas_ „ _ Date S 3u I Additional Comments: 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 FEE AMOUNT DUES AMOUNT REMITTED CK FH JRRECEIVED BY DATE PERMIT'NO. . EH;4. P, 2a I 21(REV.pix 51 EH 6y� � T, sd� {-b`0 S-~`[�'•A/ �l`� I L