91-0080 - Laserfiche WebLink

Home Browse Search

Y APPLICATION FOR PERMIT Q SAN jOAQUIN COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 p O BOX 2009, STOCKTON, CA 95201 ED *. _ EXp RE 1 YEAR FR M DATE (Complete in Triplicate) ,� .. Application is hereby made, all the work herein described. This to San Joaquin County for a permit to construct and/or inst with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San application is made in compliance Joaquin county Public Health Service 20 AC, } -Z V� MIP Cii Lot Size/Acreage Jab Address I /�S_ / / SIA Phone Owner's Name Y G� C Address ( ^^ Contracto Address 17 License N Phone_- 2 TYPE Of WELL/PUMP. NEW WELT WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ OTHER ❑ Monitoring Well [3 PUMP INSTALLATION SYSTEM REPAIR ❑ .. '{ E` DISPOSAL FLD. PROP. LINE 1_,Q_0 DISTANCE TO NEAREST: SEPTIC TANK SENWI'L) LINES FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS iINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ti-SpeW. 1rG ci}ications L�Domestic/Private Gravel Pack �=�-B-Tracy"-- , Type of Casing of Grout 4 �( -Delta, Depth of Grout Seal Type"6f I'1 Public I:� Other I ` .� 11 lirigation 4 c7�? .Approx. Depth l I Eastern Surface Seal installed by f.J. r State Work Done Repair Work Done ❑ Type-of Pump-,.._ v- - -S sling Material & Depth ' Well Destruction ❑ Well Diameter t Depth '._�-_ _��r---�---Filler Material & Depth ,,. �- TYPE OF SEPTIC WORK: NEW INSTALLATION� 1 REPAIRIADDITION I I DESTRUCTION I I available1w thin.200 feesystem ftied if public sewer. s I Installation will serve: Residence Commercial Other `� V Number of living units: Number of bedrooms '- Water table depth r Character of soli to a depth of 3 feet: "- f6 Capacity— f— Na. Compartments SEPTIC TANK. © TypelMfg ! Method of Disposal PKG. TREATMENT PLT. ❑ t',., � a "'`~------ Distance to nearest: Well Foundation Property-Line LEACHING LINE ❑ No. & Length of lines T6ra1 length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line Number SEEPAGE PI75�'-I !T Depthze--- --- .. _ SUMPS „Ll Distance to nearest: Well Foundation P or party-Line---- DISPOSAL PONDS 5 I hefeby certify that I have prepared this application and that the work will be done in accordance withSanJoaquin 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 sation laws of California." Contractor's hiring or sub contracting signature employ any person in such manner as to become subject to workmen's compen 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." Therapplicant must call for all re ired inspections. Complete drawing on reverse side. t' (� �, '+ Date: f!"�7- �/ - Signed X' Title: ! FOR DEPARTMENT USE ONLY �/ 11 55 C� y ' l 4 + I ..- Area Application Accepted by Date �} J I ci�Y iP�l Gr ._ Date 1 C,'�Gm,)ispection Y��-'-�,.� Date t �� _ Final Inspection byPit by ��i -4 - 19 Additional Comments: t-j- co S Cl� � n Uz2 Fu, Co rpc.� �� t `r X-`=1 f Applicants- Return 011 copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED (3Y DATE PERMIT"910m 1 INFO O t- d EH 13.24UtEV.I EH 71.20 t