SR0081473 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL F3EALTH DIVISION ��,' fr,.. I 1601 E. HAZELTON AVE. , PHONE (209)468-342SQr P U BOX 20U9, STOC%TON, CA 95201 -P IT EXPIRE45 1 YEAR FROM DATE ISSUED (Complete iia 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. n/;,�( 1//,,,PPP , Job Address �[��C d-�/- 0 2t� �1 City Lot 81ze/Acreage ,Z�DO Owner's Name _ �i2(i/yJt� Ql1/riti Address Phone f Contractor � _ Address License NVSc,. ?-21 Phone 3 t0� TYPE OF WELL/PUMPNEW WELL D VVELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR D OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST- SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i l Industrial ❑ Open Bottom U Manteca Ora. of Well Excavation Dia. of Well Casing Cl Domestic/Private L, Gravel Pack L-1 Tracy Type of Casing Specifications I' Public 1-1 Other I-1 Delta bepth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H P State Work Done _ Well Destruction U Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION tol- DESTRUCTION I I (No septic system permitted if publiC &ewe, rs available within 200 feet.l 1 Instalfation will serve: Residence -- Commercial_ Other„ 9�!1 Number of living units: Number Qf bedrooms j Character of soil to a depth of 3 feel: - t-•VAf - Water table depth 9,01 t SEPTIC TANK O Type/MIg Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1� LEACHING LINE Cl No. b Length of lines d Total length/size-4/ FILTER BED F1 Distance to nearest: Well Foundation �a_f Property Line e!l ip t SEEPAGE PITS IT Depth Size 3�_r. Number Z SUMPS LI Distance to nearest: Well 3 U'O ' Foundation I d r Property Lina DISPOSAL PONDS CI I hereby certify that I have prepared this application and the? 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 workmen'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 applicants r �t cal for of to ui( inspections Complete drawing on reverse side (� Signed X /tit_�f y Title: ©&,Lj )e< _ Date: FOR DEPARTMENT USE ONLY /7 Application Accepted by Date Area t�— 1 7 6)or Grout Inspection by Oa[e 1�26Final Inspection by Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P U Box 2009, Stockton, CA 95201FEE NFO AMOUNT DUE r�AMOUNT REMITTED CASN RECEIVED BY DATE PERMri NO. qG\J F„ 1'1 REV. ` L'(-