90-1470 - Laserfiche WebLink

Home Browse Search

V fi s APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION za IV . 1601 E. HAZELTON AVE. , PHONE (209)468-3420 fj P O BOX 2009, STOCKTON, CA 95201 PBMIT XP RES 1 YEAR EROM DATE ISSUED J U N 12 1990 (Complete in Triplicate) ENVIRONMENTAL HEALT Application is hereby made.to San Joaquin County for a permit to construct and/or install the work FNKftW H@gMT.?blYd. 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 ..l i Z:S._ i llUni �wil Q e, City 5fiocktOlf\ Lot Size/Acreage ro30 a X `t1 00 Owner's Name U S G 0,01-0 Address 101 S. WQ"Jce..nr 6y Phone N 0&,-'5'770 Gh:t; o T11 bpb0b SIT Contractor A Address .5t:rar. YI CA License No. $MIS 700 Phone 45 -%s9 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT X , DESTRUCTION M Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES l^C] DISPOSAL FLD. PROP. LINE 3e FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r f E Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation _fol Dia. of Well Casing y D Domesti rivate ❑ Gravel Pack ❑ Tracy Type of Casing__ ,1x.4. YD_P✓L_ - Specifications I'I Public Other ❑ Delta Depth of Grout Seal (b r 41a V r Type of Grout IT 5 cjc ' I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by d - Repair Work Dane 0 Type of Pump A)oNt' H.P. State W rk Done_ Well Destruction ❑ Well Diameter a Sealing Material & Depth Depth Filler Material & Depth S lI r c G St.-_-4- TYPE t.-_- 4_TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence L Commercial_____ Other P_Q_g_ W Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg! Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line x SEEPAGE PITS I ] - Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 must call for all required inspections. Complete drawing on reverse side. Signed Title: cillo ¢o " Date: FOR USE ONLY Application Accepted by Date Ar Pit or Grout Inspection b Dat Final Inspection Date 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 INFO LAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EM 13-241REV.r/n5) EH 14.26 ZIZKf