91-0710 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � /�"�q�y�ountv in Triplicate) 1 Application Is ereby made, San Joaqui a permit to construct and/or install the work herein described. This application is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address N� �� t�ti Y rt`� ' fi Lot Size/Acreage 2- ACi�-l�� Owner's Name Addressv� ' Phone ��}�"-�� contractor ` 4t�f�AJiress S is �`-�`a"�-- _ License No. Q'(: �✓ Phone445 5 o TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER &Niogtor Well €� I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (� Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack C] Tracy Type of Casing /Specifications Il Public El Other 1-1 Delta Depth of Grout Seal � r Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by FF_tfT9vTL Repair Work Done [J Type of Pump H.P. State Work Done _ 00 a:d c Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth vl O TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is t�,y available within 200 feet.l ti Installation will serve: Residence_ Commercial_ Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth a SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments t� PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size � FILTER BED CJ Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 i 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 applicarIkIt must call for all require aspect s. Cpmplete drawing n reverse side. �igned X OvV1 1 � `' 4 Title: � �� C'- ��_�1 r f t�4��.�Z pater FO E?E RTMENT USE ONLY �� Application Accepted by Date Area 61 Pit or Grout Inspection t Date Final Inspection by a-' Date Q� Additional Comments: a ��,f�// �t e ✓Y ,� a 6 e v� Applicant - Return all copies to: SarHoA,q%,,County Public Services. Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 EE INFO AMOUNT DUE AMMO�OU�/+�NT REMITTED CK RECEIVED BY DATE A-` [PERMIT NO. . EH A-24 fREV.1/M55pe 9ft} �_� 74H.� S`r a 1 ; LL "_-M 16 EH i426 id