90-2831 - 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 YMMIT EXPIRES 1 YEAR FROM DATE ISSUED )Ll� (Complete in Triplicate) Application is hereby made,to San Joaquin county for a permit to construct and/orlI the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and-1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Pao6srpilyy 9,alZ)61-9 Job Address 44L IV1� Q1 Vi-rZn" C�N/rr-City _ � 7dI Lot Size/Acreage Owner's Name 66 '&ZJ2C Address 93/09 Phone Contractor FX-T f/�'1 L/LRiNPraILAddres �S' License No. /��3 Phone 11 —13 If TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ (� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER rr -6 Dig Tf��T S -MOn"Oring We"-- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. FOUNDATION AGRICULTURE WELL OTHER WELL ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS w/ "—Gv!LLQ trzj� P� 6� C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation of Wel!-Ga6inq F ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ins . 1 f'1 Public 1-1 Other I1 Delta Depth of Grout Seal Type of Grout I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by iiilll Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth t" i TYPE OF SEPTIC WORK; NEW INSTALLATION 1 1. REPAIRlADOITION I I DESTRUCTION I I INo septic system permitted if public sewer is fl�J available within 200 feet.) installation will serve: Residence_ Commercial...,r Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal 1 Distance to nearest: Well Foundation Property Line 1 LEACHING LINE Cl No. & Length of lines g Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS p I 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 3 rules and regulations of the San Joaquin County i Home owner or licensed agent's signature oertifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not i 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 m t call for required insPections. Complete drawing on reverse side. Signed p 9 x— _.� Title: A57,,-,6' 6 C3 /S Date: F R DEPARTMENT USE ONLY F kO Application Accepted by e Date ' 61 Pit or Grout inspection by Date Final Inspection by u Date" Additional Comments: it) tr�[. tLvrS• JJ� m Applicant - Return all copies to: San Joaquin County Public Health Riziu Services, Environmental Health Permit/Services t 1601 E. Hazelton Ave., P 0 sox 2009, Stockton, CA 9520INVIR(DWIIENTALKALT�I FEE AMOUNT DIE AMOUNT REMITTED CK RECEIVED BY DATE MV INFO (�] CASH . EH 13.2 (REV.iixsl �C� kc)z)(�