91-0856 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HA2ELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PTsRI[IT MIRES 1 YEAR FROM DATE ISSUED (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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address O6 A City Lot Size/Acreage Owner's Name �® �-.I 5 c 71, Address Phone Contractor 5 Caves Address 1/�O /��`4o z��er �/ - License No, � flof? Phone R3' 5C TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION El Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES-. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing [l Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications 1'} Public M Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ Welt Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Material 3 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION E DESTRUCTION i (No septic system permitted if public sewer is f available within 200 feet.) 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 SEPTIC TANK X Type/Mfg P"/1. r./Pn3 F,&4, 1' � capacity_&rD _ No. Compartments PKG. TREATMENT PLT. 0 1 01 Method of Disposal Distance to nearest: Well Foundation Property Line l� 1 LEACHING LINE Cl No. & Length of lines Total Iength/size__ZQAkZZ FILTER BED Distance to nearest: Well . __ _-_- Foundation _ /P, Property Line S SEEPAGE PITS It Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI 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 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 workman's compensation laws of California."Contractor's hiring or sub-contracting signatute 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 applica9lilst call for all required inspections. Complete drawing on reverse side. _ Signed (f / Title: �CCc%r�b Date: /�/ t-- �/ �l OR DEPARTMENT USE ONLY q Application Accepted by ^"�' Date L t Area Pit or Grout Inspection by Date Final Inspection by44 A- Date I Additional Comments: Applicant - Return all copies to: San Joaquin County Plic Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CK 11 RECEIVED BY DATE INFO CASH PERMIT'IVO. EH 13-2A IREV.i/n51 , vz> 1,21 EH 14-25f� •/