SU0005061 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 pa 1 .M Lck_� City t Cjy7�L - Fs._Lot Size/Acreage-,_- /5 x 13SL'X 1 TSG Owner's Name _1t) tt11,CC1'± l,iX, Of_,' Address 1 ��. �1�7�� nCL€��C Phone Contractor e Address r _ ` License No. / Phone — TYPE OF WELL/PUMP: NEW WELL ❑ WELL RE ACEMENT Cl DESTRUCTION Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O OTHER O `- Monitoring We11S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom O Manteca Dia. of Well Excavation pia. of Well Casing X-Domestic/Private ❑ Gravel Pack O ti� Tracy Type of Casing— �__ Specifications'�x(•IW_A LUQ IL-0 I'I Public 1-1 Other FI Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U T p Type of Pump ll H.P. StaSo Work Done _ Well Destruction O Well Diameter xt1 Sealing Material i Depth __ Depth s" ° "�� Filler Material i Depth I-- TYPE --TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sawer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of Irving units: Number of bedroo s Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line PAYMF,,N k LEACHING LINE C1 No. d Length of lines Total length/size R 1� FILTER BED O Distance to nearest: Well Foundation Property Line SF � 4 ITTVSEEPAGE PITS 11 Depth Si.. r Number SAN V` SUMPS LI Distance to nearest: W Foundation Property Lina 11Bl I Q W �.Jo�` DISPOSAL PONDS ❑ ENVInU�MP�j�' L�� 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, 1 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 compenss- tion laws of California." The applicant must callfor-allrequired inspections. Complete drawing o reverse side. q Signed —�--f Title: �c,l �t.�� Date: / 1Z_5� 4J& FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by , Date l 7 Final Inspection by Date Additional Comments: ^ m - ^ D-D 1, k Appli(ant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE? INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. • EH 1424141 1ixs� P1� VIU� " lq-nt- EN Lis f�'� .L.