SR0007636 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PEPWIT SAN JOAQUIN COUNTY PUBLIC HEA SERVICES ENVIRON1iENTAL HEALTH DIVIVI SION iVED P O BOX 2009, STOCKTON, CA 95201 RECt (209) 468— 3420 OCT 0 5 1955 PERMIT EXPIRES 1 YEAR FROld AAn IssuafFNVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES Application is hereby made to San Joaquin County for a Permit to construct and/or install the work herein described. This applicatio❑ is made in compliance Frith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sun Joaquin County Public Health Services. COIt:i+f�7 c/r.6 F 1� Jot) Address /571 rbymh,,. C�Lr,A bi/ryt 'O's -5-1.9n! n "O'o City< T ,ej4r/YI Lot Size/Acreage nereuy canny tnat I neve prepared this application and that the work will be dons in accordance with Sart Joaquin county ordinances, stela 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 puriotmance of the work lot which this permit is issued, I shall not employ any person in such manner as to become subjeCt l0 workmen's compensation laws of California.- Contractor's hiring or sub -contracting signature canities the following: "I certify that in the performance of the work for which this permit is issusd, I shall employ persons subject to workman's compensa- tion laws of Celifornla." The applicant m st call lir all required inspections. Complete drawing on reverse side. Signed // Title: ('OrlS4Yia7— Date: 01211Fs FOR DEPARTMENT USE ONLY 5 Application Accepted by Date 16 9J Area 16 Pit or Grout Inspection by Additional Comments Date Final Inspection by ��L� Date Applicant - Return all co ies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � � �� /l � 3L= ENVIRONMENTAL HEALTH DIVISION PERuIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 05201 13 24 tAfv. irepr FEE NFO AMOUNT DUE Dwner's Name M.S216Chp2 Address 16-3 3 W. Lt) n l Nut �GeL•yt.. Phone(Z:C 5444-/221 RECEIVED By P—o.3osC /`2580 -7�� Contractor / CG Address .,51 f.SBlG License No -7M,57&6 Phone( TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT Cl DESTRUCTION 0 Out or Service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR E7; OTHER �( Mgqnitoring well o Qfor P)eob<s DISTANCE TO NEAREST: SEPTIC TANK _/Y/4 SEWER LINES_ DISPOSAL FLD. A//i� PROP. LINE / FOUNDATION 70AGRICULTURE WELL �_ OTHER WELL �U' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f.l Industrial '' / ❑ Open Bottom O Manteca Die. of Well Excavation Z Dia. of Well Casing Aloo 4 Domestic/ Private - ❑ Gravel Pack ❑ Tracy Type of Casing &Ipc Specifications AIM O Public (X Other ❑ Delta Depth of Grout Seal Typo of Grout_isj'M14 0 IrrrUatron 2CL Approx. Depth ❑ Eastern Surface Soul Installud by 4�11�r/bci�✓ Repair Work Done U Type of Pump H.P. • State Work Done _ '.bell Destruction O Well Diameter Sealing Material i Depth — Depth Piller Material I Depth _ — TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR /ADDITION 0 DESTRUCTION CI (No septic system permitted it public suwer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other .Number of living units: Number of bedrooms Character of snit to a depth of 3 feet: -----Water (able depth SEPTIC TANK ❑ Type/Mfg Capacity___.__ No. Compartments PKG. TREATMENT PLT: O Method of Disposal Distance to nearest: Well Foundation _ Property Line .EACHING LINE 0 No. b Length of lines _ Total longth/size FILTER BED 1.1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS II Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O nereuy canny tnat I neve prepared this application and that the work will be dons in accordance with Sart Joaquin county ordinances, stela 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 puriotmance of the work lot which this permit is issued, I shall not employ any person in such manner as to become subjeCt l0 workmen's compensation laws of California.- Contractor's hiring or sub -contracting signature canities the following: "I certify that in the performance of the work for which this permit is issusd, I shall employ persons subject to workman's compensa- tion laws of Celifornla." The applicant m st call lir all required inspections. Complete drawing on reverse side. Signed // Title: ('OrlS4Yia7— Date: 01211Fs FOR DEPARTMENT USE ONLY 5 Application Accepted by Date 16 9J Area 16 Pit or Grout Inspection by Additional Comments Date Final Inspection by ��L� Date Applicant - Return all co ies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � � �� /l � 3L= ENVIRONMENTAL HEALTH DIVISION PERuIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 05201 13 24 tAfv. irepr FEE NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT N0.