90-2612 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT )SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT E%PIBEOIYEAR FROM DATEISSUE (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 coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �(�:.CJ t� 51? �� Cit e ! Lot Size/Acreage Job Address Y - Owner's Name " �G S Address , ' * Phone Contractor/, �,.�,r�A I /lam �e h r Address &x X131 lsey&�.7Lrj%I License No. r' Fhone 11e�^ .ids TYPE OF WELL/PUMP. �NEW WELL Cl V WELL REPLACEMENT ❑ DESTRUCTION 0 Out 'of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well'Casing LJ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications R Public CI Other 'O.Delta Depth of Grout Seal Type of Grout CJ Irrigation _.Approx. Depth ❑fEastecn ,. ,Surface Seal Installed by F." Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter `--.. Sealing-Material & Depth + S tDepth a..Filier Idaterial, i Depth.--. W _ TYPE OF SEPTIC WORK; NEW INSTALLATION ; REPAIRIADDITION Ll DESTRUCTION-;('(No septic system permitted if public sewer is j available within 200 feet.) r Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms .' �. Character of soil to a depth of 3 feat: Water-table depth SEPTIC TANK Type/Mfg FL QA CiZr r- Ce aCit �' i F p y�"�No. Campsrtrriants PKG, TREATMENT PLT. ❑ � .� �/ r . F Method of Disposal Distance to nearest: r Weli Ja.3 t Foundation L.� Property Lina LEACHING LINE or No. & Length of linesTotal length/size FILTER BED f=1 Distance to nearest: Well ZOAT Foundation 10f Properly Line SEEPAGE PITS Depth 'I �t i Size �� Number } SUMPS Li Distance'to nearest: Well �t '' f44f r ...!•�as�� ..Foundation Property Line _Id 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 taws, and rules and regulations of the San Joaquin county t - 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 work ma'n's-compensalion 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- tlon laws of California." The applicant must call for VI required inspections. Complete drawing on reverse side. Signed ` t Title3 . 2a .__ -Data: fU P ! FOR EE DEPARTMENT USE ONLY Application Accepted by -- Date �G�U 2C Area r �Pi r Grout Inspection by ,(Q � � ��^-` t ` Z"y0 -�:r_D;tte.- Fina! Inspectian.by- .. � Data.-- Additional Comments: Applicant - Return all copies. to: SAN JOAQUIN-COUNTY PUBLIC HEALTH SERVICES - ENVIRORMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 98201 IEEE AMOUNT DUE ! JtAMODUNfT REMITTED /�CAS� RECEiVEO 8Y IDATE PERMIT.NO. . EH 13-24 IREV.I/A$) ! ..}{, ! ` !` i.� �� 10/// 1 Q `� 'vt. EH 14.26 f t,