FIELD DOCUMENTS_FILE 2 - Laserfiche WebLink

Home Browse Search

`76 [ APPLICATION FOR PERMIT V SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-34:20 P O BOX 2009, STOCKTON, CA 95201 I PERMIT MIREg X YEAR FROJIDATE ISSUED (Complete in Triplicate) Application Is hereby made.to Sass Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862'and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �J ��h2 I�DQ� City rQ Lot Size/Acreage !/3 SO ia-tk.� S�� Svicngri jd.) 3{o' 4 Owner's Name $t Address P1 4sa-+' T C.4 58 Phone 2o 6 3- X7 r I �, Address _ __Licens"e[l�tl?LL P TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL / PtTS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exc ation Dia. of Weil Casing Cl Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications I'I Public 0)her n Oelta Depth of Grout Seal a-3 3 Type of Grout 10 I I Irrigation -Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I l (No septic system permitted if public sewer is available within 200 feel-1 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. ❑ Type/Mfg Capacity No. Compartments * PKG. TREATMENT PLT. ❑ M'Es'tPnt� Distance to nearest: Well Foundation ProperRle �RLY- LEACHING LINE ID No. & Length of lines Total length/11i FILTER BED ❑ Distance to nearest: Well Foundation I tg)AQ111UL0UNIY PUBLIC HEALTH SERVICES SEEPAGE PITS 11 Depth Size N„%VJRONMENTAL HEALTH DIVISION SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, 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 f r all r quired inspections. Complete drawing on reverse side. _ Signed Title: . _ Date: 67 3 OR DEPARTMENT USE ONLY 247.4Z) Application Accepted by Date Area L- Pit or Grout Inspection by Date Final Inspection by Dat f �iAdditional Comments: � daa -4 � Applicant - Return all copies to: San Joaquin County Public Health ® �Lt��D�j Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 $ox'2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PER 1'NO. INFO CfrA�SH //yy /y} +rj . EM 13.24(REV.,iK ,..(r'r� O "�_ ! �•�• l3-eLl/ EH;1.24