91-1250 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENV IRONUENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468--3420 P 0 BOX 2009, STOCKTON, CA 95201 PFMIT EXPIRES 1 YEAR_FRQM DATE ISSUED. (Complete in Triplicate) Application is hereby made to Sen Joaquin County for a permit to construct and/or install the work herein described. This application is made in courpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public pHealth �(Services. ✓IJ Job Address -L + /Y 11ex City Lot Size/Acreage t/ zU Owner's Name 1 n &I-,- Address 14 x s U... �'��f - - — Phone �/' v V' N License No, Phone�4� al! Contractar.�i�►+�_ .C..CJ�� Address,�� TYPE OF WELL/PUMP: i NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER © Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE Fl3UNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE T PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f_l Industrial ❑ Ope Botiom ❑ Manteca Die. of Well Excavation Dia. of Well Casing C_i Domestic/Private ❑ Giavel Pack ❑ Tracy Type of Casing Specifications l'I Public fa Other fl Delta Depth of Grout Seal Type of Grout I i Irrigation —.Approx. Depth I I Eastern Surface Sedl Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth r—' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION A, DESTRUCTION l I (No septic system permitted if public sewer is (� available within 200 feet.l r� Installation will serve: Residence '� Commercial e Other Number of living units: I_ Number of bedrooms __4-___ I�0 !a Character of soil to a depth of 3 feet: r Water table depth .- SEPTIC TANK ❑ Type/Mfg. Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE & No. & Length of lines c) Total length/size RC1 d FILTER BED Cl Distance to nearest: Well Al�4F Foundation 34) Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 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 u calf fora re uired inspections. Complete drawing on reverse side. y �u'W C.f— Date: Signed Title: (�_ R ENT USE ONLY �t p Application Accepted by r,� - --. Dale �'1" l Area Pit or Grout Inspection by Date Final Inspection b, . � 1 Date / Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/ServicesLj)\�j� 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. . EN 13-24(REV.1r1451 _S4 1 Iq_,�bO 11 1 t 15-0 �`(1�� t �•+r EH 14.26 1