91-1154 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT iZs-rt 1' lb: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES gp��eq C'�zt:. GNfu�tl3L ENVIRONMENTAL HEALTH DIVISION A-R1,3= Tbkk SALUIEQ'-Z 1601 E. HAZELTON AVE. , PHONE (209)468-3420 3176 OL-ifA, P O BOR 2009, STOCKTON, CA 95201 U4 k2..SALZeVy VEISMi c.A 9S`6`t 1 EXPIRES 1 YEAR FROM DATE ISSUED 000 P Complete in Triplicate) Application is hereby made,to San Joaquin Cdunty 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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. 1 � Job Address f 6T , cl' 1D6k. Iti+DUSJ LIAL P1��c ty gpf-y Lot Size/Acreage 46M CrLaFr- 2C090 Owner's Name i7wel-I IL ss a-NiDto Phone�l6 M(._ 36c�o `3CE3 01-A f-c- C 12[L� S�S.T6.B CDnlractofO*F 9DR �tLt-� COs_ JtG, Address RN-a C V y2 License No. 5,9qZ _ Phone �� "q'S TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well Cl PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER )9. Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK NIA - --- SEWER LINES DISPOSAL FLD,t— PROP. LINE FOUNDATION . NIA _..-, AGRICULTURE WELL N OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing Ca Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications FI Public Ia Other I-1 Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done 0 T pe of Pump H,P. State Work Done ell Destruction ❑ B44."meter C ^ Sealing Material & Depth !. Enl T f REt4T CA3 kT& Cs V6 rar_liNa(.Al. Depth 0"Z!� Filler Material & Depth GRAI T- 1 F 6f24>0r-1DI.at �xr�tAl2•t�t lora dCfin16.`� - ��.CX:i`�Tt�� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. G Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED L) Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 subcontracting 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 applican!-TA applicant-TAcall for all r red in tion Complete drawing on reverse side. � �ff•• sywr= Z-NCWF- -51-1'iIAt Signed X � �F.� Title: Date: FO DE FITMENT USE ONLY Z= Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by 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 AMOUNT ��/DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. • EH 13'24 ,t�J � 1 1 EH t4.2a It �l