90-2132 - Laserfiche WebLink

Home Browse Search

i APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 pFi MIT _EXPIRES 1 YEAR FROM DATE ISSUED ' -(Complete in Triplicate) �'fQ g'��' .S'4 /mac_�r,•v ct Application is hereby made,to�S Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Jpaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San + Joaquin County Public Health Servio s. ✓ ,/L t!!� (y U /� �/e Cy�� ?0 Lot Size/Acreage Job Address mitit Owner's Name 0k f�G/ ddless 34�S~ / iC FN,EV` Avg Phone C--5"7 g lh�r$�El �Conttactar�Y�JA1� Nut "ddress F License No. �i� 3� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONOut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monito� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD, PROP. LINES FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic)Private ❑ Gravel Pack -.- .0-Tracy Tylz�,of_Casing -:__ --- Specifications i'1 Public Cl Other f) Delta Depth of Grout Seal Type of Grout I I Irrigation ____Approx. Depth I 1 Eastern Surface'Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done (� Well Destruction ❑ Well Diameter Sealing Material & Depth Depth i Filler Material & Depth _S N.J, \J �g TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION i I INo septic system permitted if public sewer is f available within 200 feet.1 y ` Installation will serve: Residence:.,,. Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth EV SEPTIC TANK. © Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ra Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line th SEEPAGE PITS 11 Depth Size r Number F SUMPS LI Distance to nearest: Well Foundation Property Line 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 laws, and rules and regulations of the San Joaquin county . 4 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issue , 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,coniracting signatures" 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 must call for all required inspections. Complete drawing on reverse side. signed X ou � � Title: T Date: D ONLY Application Accepted by Data — t res p ` Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant _ Return all copies to: Sen Joaquin County Public Health Services, Environmental Health Permit/Services 1603 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AUNT DUE AMOUNT REMITTED CK 01 RECEIVED BY DATE PERMIT'NO. INFO CASH (/�f� }� �/ C/�EH17.25IREV.IiKsi `1.70 �a- �o•f10 >dYoz a�5—C 110413,R, f .t-28