90-1884 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 - REIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) C 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. 51+9 and 1862 and the Rules and Regulations of San I Joaquin County Public Health Services. F Job Address City Lot Size/Acreage I Owner's Name�g' HT1 i be S,�h _-be Q% Address 1 a 1/ phone -74D�H Contractor A Address License No 3 Phone r TYPE Of WELL/PUMP: NEW.WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ r PUMP INSTALLATION ~' ' SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK ' �._ SEWER LINES DISPOSAL.FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f 0 Industrial v Open Bottom ❑ Manteca Dia. of Well Excavation � _ Dia. of Well Casing f Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing >Mc� i r Specifications I"I Public i-1 Ocher 1-1 Delta Depth of Grout Seal Txp�j f Gro G�- _ I I Irrigation C4�,.Approx. Depth i-[ I Eastern Surface Seal Installed by f'b f 1 yi411 Repair Work Done 0 Type of Pump : yL H.P.Q _ State Work Done_ `` Well Destruction ❑ Well Diameter Sealing Material & Depth f _ Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION 1 I DESTRUCTION I I (No septic system,permitted if public sewer is f� available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms _ t Character of sail to a depth of 3 feet: Water table depth I SEPTIC TANK: O T e/Mf 9 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance-id nearest: Well Foundation Property Line G LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number i f SUMPS L l Distance to nearest: Well Foundation + Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, 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; l 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: 1 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 must call for all required inspections. Complete drawing on reverse side. f SigneX t Title: CG. _ Date: + FIN DEPARTMENT_ USE ONLY ` ! Application Accepted by ,C .a: ___ Date L� � --- --- Area Pit or Grout Inspection by �( Date d— Final Inspection by Additional Comments. Applicant - Return all copies to: San Joaquin County Public Health s ,� Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 f fEE- AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT'NO. 1 INFO L=ASH I + EM 13-24{REV.iins) ,� bC7 25-7k +oma �U4 EH T1.1¢ i ChJ n _