SR0043178 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PF r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E k;E I E"- ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468--3420 n � flP O BOX 2009, STOCgTON, CA 95201 AUG 2 8 1w,Jo EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMIEN I AL HEALTH f (Complete in Triplicate) PERMIT%SERV110ES 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 CitylLhlbl Lot Size/Acreage 1 [ O7rI3iam,�� Address Phone co� IIj� cerise No'�7�lS� Phone k4f TYPE PF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATfU�" / SYSTEM REPAI OTHER ❑ Monitoring well ❑ DISTANCE TQ' EAREST:, SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _T P INTENDE'USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing �- 4i`estic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public n Other ❑ pelta Depth of Grout Seal Type of Grout 1 I I Irrigation _ _Approx. De I Eastern uriace Seal installed b Repair Work Done U Type of Pump� H.P. _ e or Well Destruction ❑ Well Diameter Sealing Material & Depth t�W � 1' Depth aO�T Filler Material & Depth TYPE OF SEP=TIC WO". NEW INSTALLATION I I REPAIR/ADDITION I t DESTRUCTION t I (No septic system permitted if public sewer is J available within 200 feet.1 Fi Installation vVilll server j Residence-' ° Commercial_ Other Number of living units: Number of bedrooms i Character-of,soil to a depth of 3 feet: Water table depth (y SEPTIC TANKS 0---Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT-,.. ❑ f S .. ..,. :Method of Disposal Distance to nearest: Well Foundation Property Line F'r, LEACHING°LINE ; ❑ No, B Lcn th of lines Total_I,n z. 9 q 9t1 ize FILTER,BED ❑ Distance to nearest: Well FoundationProperty Line C� SEEPAGE PITS I I Depth Size Number \ SUMPS CI Distance to nearest: Well Foundation Property Line �. DISPOSAL PONDS ❑ I hereby certify that 1 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 iii 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 issuedr I shall employ persons subject to workman's c mpensa- tion laws of California." The applica ust call or r uire inspections. Complete drawing�onr5ers"e Sig d 11 Title• Date: " OR DEPARTMENT USE ONLY Application Accepted by Date �J�B�� Area ,-211 Pit or Grout Inspection by _ Date Final Inspection by ` Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health a Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Bax 2009, Stockton, CA 95201 FEE CK 9 i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. REMEH 13-24(REV.I i n si 14.25 O Q 1