91-0169 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT y- l SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 PEMIT EXP RES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) � Application is hereby trade to San Joaquin'County for a permit to construct and/or install the work herein described. This I 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. L� drlwo 2I`a'= / Cit Lot Size/Acreage 'E Job Address .L� `S r Y Owner's Name /� Address Phone 91 r _N 7 Contractor Address License No< Phone of service weii D TYPE Of WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out Monitoring Well r PUMP INSTALLATION ❑ it f 1 SYSTEM REPAIR El OTHER ❑ �LS.EWER LINES I ' DISPOSAL FLD, PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK "._ � s Y• FOUNDATION - AGRICULTUREWELL OTHER,WELL ` PITS/SUMPS INTENDED.,USE TYPE OF WELL PROBLEM AREN,4 A COTRUCTION SPECIFICATIONS ❑ O / • '• Dia. of Well Casing ED Industrial �, pen Bottom ❑ Manteca Dia. of`Well Excavation Cl Domestic/Private ❑ Gravel Pack El Tracy Type of Casing � Specifications � I'1 Public Cl Other C1 Delta Depth of'Grout Seal 1 Type of Grout I I Irrigation t —.Approx. Depth I I Eastern Surface Sdal Installed by Repair Work Done ❑ Type of Pump H.P. / i 1 ` State Work Done _ Sealing Material'& Depth r Well Destruction ❑ Well Diameter LPN Depth �- Filler"Mat & Depth i V E TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADOITI N I ESTRUCTION I 1 INo septic system permitted if public sewer is i t-- l, r available within 200 feet.) Installation will serve:} Residence�Commerciat Other 3 } S 1,' Number of living units: Number bedrooms r -- Character of soil to a depth of 3 feet: �— ^'r •`Water table depth Capacity `� = r''`� L,-No. Compartments SEPTIC TANK. Type/Mfg �,. y n PKG. TREATMENT PLT.❑ Ff ;6 4 Method of Disposal l ' Distance to nearest: Well ,'Foundation Pfd{ierty Line LEACHING LINE Total length/size No. & Leg ngth of tines � ..__ . . FILTER BED CI Distance to nearest: Well l.Mf -- Foundation �0 -- - Property Line l SEEPAGE PITS I&K Depth 5 Size� Number Z �" SUMPS 3 CI Distance to nearest: well�0 l Foundation`,X �y�t Property Line I`E{ DISPOSAL PONDS ❑ r r I hereby certify that I have prepared this application and that thework will be done in accordance with San Joaquin county ordinances, state laws, and ' rules and regulations of the San Joaquin County.' i i i Home owner or licensed agent's signature certifies the following: .'I_certify-that-in.the.performance of-the.work tar which this permit is issued, I shall not employ any parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature f certifies the following: "I certify that in the.performancs of the work for which this permit is issued, I shall employ persona subject to workman's compensa { tion laws of California." ( Theapplicant must call for all re fired inspections. Complete drawing on reverse side. ► Signed Title: Date: R DEPARTMENT USE QNLY._ Application Accepted by r Date - Area 6�1 Grout Inspection by Date JLi- . Fines Inspection by p ate I Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. INFO -j I �'a.3�l 1 `11tCa�3 1 . EH 13.21(REV.frssl —� EN 74-28 111 r�D '