90-2144 - Laserfiche WebLink

Home Browse Search

x APPLICATION FOR PERMIT ,,, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES p ENVIRONMENTAL HEALTH DIVISION 1601. E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201. NX,', PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDD (Complete in Triplicate) P� 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 1$62 and the Rules snd Regulations of San Joaquin County Public Health Services. , / f�� '}�( � [� 60 9 Job Address �� E. "`146/ '' 4" -T "'" ST City .]A� Lot Size/Acreage �-J f Owner Name Tip 1"I �'u t `r"��N,`' Address SULJ ?` IEPhone fT Contractor AddressL,_�3i/ �� his" /�yG LceseN Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCT ONKOut of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ S6P OTS ❑ Monitoring Well CJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing FI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I.l Public El Other n Delta Depth of Grout Seal Type of Grout I I lrrigation Approx. Depth I € Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction O Well Diameter -'Searing Material & Depth Depth _"Filler Material,& Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR IADDITION i I DESTRUCTION o septic system permitted if public sewer is / available within 200 feet.) Installation will serve: Residence t! Commercial____, Other (�.� Number of living units: / Number of bedrooms �— L� 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity— No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED C] Distance to nearest: Well Foundation Property Line �\ SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies 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 nst call for all req I inspections. Complete drawing on reverse side. Signed X Title: J 112 Date: ��FO �DEPAR�TMENT USE ONLY Application Accepted by Date -tl Area Pit or Grout inspection by �i Date Final Inspection by Date j X70 Additional Comments: _ /1�Q',c. 9� l f z) f�i T U` �� ' Z2r'l.1.2 a Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2D09, Stockton, CA 95201 FEE INFO OUNT DUEA UNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH 1,.24 IREV.r IN 5f rry !!2(f, J� 12`6 (