90-3034 - Laserfiche WebLink

Home Browse Search

r } f ' 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 PERMITF XPIRES 1 YEAR FROM DATE ISSUBP (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. 2-0 ,7 �k r,.,.L RD .e f� I Job Address " O ' - -L� Gity fi��T L_ Lot Size/Acreage Owner's Name 1©o [ ✓ V' L a'i'r-- Address Q �' i 1'efe Api Phone 2—, 90 Contractor_ � - __Address. Lcense'No. Phone TYPE OF WELL/PUMP: �� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well I DISTANCE TO NEAREST: SEIPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial EJ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing r FI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications h I"1 Public 1.1 Other n Delta Depth of Grout Seat Type of Grout N t I I�rigalion IM .Approx. Depth I I Eastern Surface Seal Installed by Cn Rep;ir Work Done ❑ Type of Pump H,P. State Work Done �+ Wel Destruction ❑ Weill Diameter Sealing Material 6 Depth l Depth Filler Material b Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION [;P'—DESTRUCTION I I INo septic system permitted if public sewer is available within 200-feet.) InlsItallation will serve: Residence ✓Commercial— Other T _ Number of living units: Number of bedrooms Z Y f Character of soil to a depth!�of 3 feet: " Water table depth ! SEPTIC TANK. W�-Type IMfg"" �- " �� 'CP-e �— Capacity it 2-9.0 -- No. Compartments 2-. PKG. TREATMENT PLT. ❑ I f r Method of Disposal L�4C1R fl_e N' r Distance to nearest: Well Foundation ' Z Property Line `� O r r �i5-p—ar, m If "� o Z -2Z LEACHINGLINE i�No. & Length of lines _-., --��• Total Isngth/size F ER BED r (��''�Di Wnce to ne t: Well p Foundation -70 Property Line co A Y 0 6 1 SEEPAGE PITS 11 .I�Pepth Sire Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ E I heneby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and j 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, f 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 must call for alt,require 'nspec ' s. Ca eta drawing on reverse de. "I� (/ Signed X, Title`. Date: FOR DEPARTMENT USE O LY . Area l Application Accepted by Date Pit Ir Grout Inspection by 'll Date Final Inspection by Date l lq 10 ! 11 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health 1� Services, Environmental Health Permit/Services 1I 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CK INFO RECEIVED BY DATE PERMIT"NO. C� EH t3-241REV.I/KSi /I "� !! / -� At7 f� �y Lr Lc7a- 303 Y y EH 84.25