SU0003443 - Laserfiche WebLink

Home Browse Search

} APPLICATION FOR PERMIT ! SAN JOA.,JIN COUNTY PUBLIC HEALTH SERVES ENVIRONMENTAL HEALTH DIVISION +. P O BO% 2009 , STOCKTON, CA 95201 (209) 468-3447 /;:::N( p1PvI3fITT E%PIRES I YEUR FROM DATE 10-UM \0[pry (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 tcaplisnce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �( Job Address ��. -- S`¢1,2 I(Af I� Cityr— — Lot Size/Acreage Owner's Name AC to , -m l 4C- Address Pa •,a,ole --2!5 !l? e.C.ast Phone 9 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT r DESTRUCTION 0 Out of Service cell ❑ Monitoring Welk ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER xavSS Co,�1r+Yr- wl'+ DISTANCE. TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F PROP. LINE FOUNDATION AGRICULTURE WELL OT E WELL PITS/SUMPS .— INTENDED_USE TYPE OF WELL PROBLEM AREA CONSTRU ION ,IPECIiFICATIONS r_l Industrial 0 Open Bottom ❑ Manteca Dia. of Wei vaDia. of Well Casing U Domestic/Private CI Grayel Pack ❑ Tracy Type of Casing Specifications• - s M Ptiblic 1-I Other ❑ Delta Depth of Grout Seal Type of Grout {! CI Irrioation Approx. Depth ❑ Eastern Surface Saal Installed by f Repair Work Done U Type of Pump H,P, State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth G Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION M (No septic system permitted it public sewer is available within 200 feet.i G� Installation will serve: Residence — Commercial_ Other Number of living units: Number of bedrooms Character of &oil to a depth of 3 feet: Water table depth f SEPTIC TANK- ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. b Length of lines Total length/size FILTER BED i_] Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ I hereby eertily 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 subcontracting signature een;ifies 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 tail for all required inspecti� Complete drawing on reverse side. �C Signed Title: Date: e14 1q, FkK DEPARTMENT USE ONLY Application Accepted tryDro A Sate Area / Pit or Grout Inspection by Date Final Inspection by Dets f / Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PER1tIT/SERVICES ` 445 N SAN JOAQUIN, P O BOX 2009, STUCKTON, CA 95201 FEE AMOUNT DUE AMOUNT RfMiTTED CAS-i4 RECEIVED BY DATE PERMIT 140. INFO ��;;� J� � 9 /J . EH 13-74 tREV.I/"$) i 4-�c� 7L ! 1 f EH'A-26