91-0171 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 it PERMIT EXPIRES 1YEAR 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 coOpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County public ,CHleaith Services. Job Address //'1 611114/. 't►m t✓ /-G-,:er _..._ City � G ` Lot Size/Acreage Owner's Name I E"t f!r'o+✓/� S Address 11A18 'L/I 1)�°`"""—c— /A/ 57,4 rlt, , Phone '7"177" �f�"22 �kl`dors-. S)drk� Contractor Address _eZ�Z� „mY1:�C, License No UAi Phone X65 F7/2 TYPE OF WELL/PUMP: �� NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .26-` DISPOSAL FLO. Alh PROP, LINE FOUNDATION _ AGRICULTURE WELL N'4 OTHER WELL `fie- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ii n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation F� Dia. of Well Casing 12 fa Domestic/Private Griavel Pack ❑ Tracy Type of Casing— F ,i _.... Specifications �-•, I'1 Public is Other Delta Depth of Grout SealType /Ve_-�-! r al Grout __ I I Irrigation -.1. pprox. Depth I I Eastern Surface Seal Installed by6&14vh- Repair Work Done 0 Type��,f Pump H.P. State Work Done_ Weil Destruction ❑ WellDiameter Sealing Material & Depth NcR Grp. �ya-;ot d y? Oepo" Filler Material & Depth ,X& 5c- .r' y] =�Y/ I TYPE OF SEPTIC WORK: NEW� INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence____. Commercial____. Other Number of living units: Number of bedrooms Character of soil to s depth of 3 feet: Water table depth SEPTIC TANK. ❑ ,Type/Mfg Capacity' No. Compartments PKG. TREATMENT PLT. ❑ '11 Method of Disposal Ditance to nearest: Well Foundation Property Line SIM LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line I I--I SEEPAGE PITSl I Depth Sire Number l SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 i 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." Contractors hiring or sub-contracting signature certifies the following: "I certify teat 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." i The applicant must call far all required insPections. Complete drawing on reverse side. Signedx- Title: Date: 111 15 9 0 FOR DEPARTMENT USE ONLY _ Application Accepted by Z �= Date r AfeB 7 y'i I(,r r Pit or Grout Inspection by jntio Q „_. Date�� Final Inspection by - DateZZ02 I�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 CASH RECEIVED BY DATE PERMIT'N Em 13-24 1 REV. EH A•2e y I! f II 7