91-1596 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQIVIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION `t ,� � 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 9V01 2EN11 EXPIRES 1 YEAR FROM DATE FSSUED (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 City/ �- City Lot Size/Acreage Owner's Name 6sc6;ed.ce/ Phone Contractor Address License No. J v_ e'Phon�""� S�7 TYPE Of WELL/PUMP: NEW WELL ❑ WELL REP ACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDA AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROS EA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom Cl Manteca of Well Excavation Dia. of Well Casing 1.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of _ .specifica�ns,: U) Public la Other n Delta y Depth of Grout Sea Type of I I Irrigation ___.•Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.), Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms ._t Character of soil to a depth of 3 feet: Water table depth F i SEPTIC TANK ❑ Type/M19 Capacity No. Compartments Y PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lineal /1 Total length/size 4417 FILTER BED n Distance to nearest: Well FoundationProperty Line SEEPAGE PITS 11 Depth Size �� Number SUMPS Ll Distance to nearest: Well Foundation Property Line__e2,Q_; 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 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: "1 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 ca I requir tions. Complete drawing on reverse side. p� Signed X__ Title: —d-2 Date: 7 L FO EPARTMENT USE ONLY Application Accepted by r)"D ,'. a ,06"k Date Area Pit or Grout Inspection by Date Fine! Inspection by Date , dditionaf Commenta: f Yi�je T pr 47 Applicant - Return all copies to: San Joaquin County Public Health t � TT Services, Environmental Health Permit/Services W4CI A 3" 1601 E. Hazelton Ave., P 0 Box 2008, Stockton, CA 95201 1/ 6,llc� e_; yr�f FEE ®® 1 vrl cry► IK INFO AMOUNT DUE AMOUNT AMO1UNI��T(�REM/�rTTED CASH RECEIVED BY DATE PERMIT NO. . EFS 13.2/iHEV.1iKSiC 1 ) 4 co j 1 t. a" � �� T'Z�1 lt-iS� EH 11.26 J t l �]