90-2451 - Laserfiche WebLink

Home Browse Search

APPLICATION PPR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION MACNADO 1601 E. HAZELTON AVE. , PHONE (209)468-3420 , IINC. P- 0 BOX 2009, STOCKTON, CA 95201. 247 N.Jacktone Road , REMIT EXPIRES 1 YEAR FROM DAIR ISSUED Stockton, California (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 cotaplia.nce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job AddressL /City IL %%-deL-"L`T- Size/Acreage Owner's Name [�i�G. (a_,,,,,,, Address-&*-^— Phone Contractor tr Q r? Address License No, �D-Phone TYPE OF WELQPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Wei 1 ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR �k OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLO. PROP. LINE 1 .E FOUNDATIONhA AGRICULTURE WELL t`` OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS" Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing Specifications FI Public f:l Other n Delta Depth of Grout Seat Type of Grout I i Irrigation -Approx. Depth I I Eastern Surfs a Seal installed by Repair Work pone PQ Type of PumpH.P. CState Work Done U Well.Destruction ❑ Wall DiameterMa Sealing erial & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR,/ADDITION I !_ DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.1 Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK ❑ Type/Mfg Capacity r No. Compartments PKG. TREATMENT PLT. ❑ .. Method of Disposal Distance to nearest: Well Foundation ,Property Line LEACHING LINE I-) No. & Length of lines Total length/size ` FILTER BED D Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number 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 ; Home owner or licensed agent's signature certifies the following: "I cartify,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 comp nsa- tion laws of California." The app' m call for all r d ins etion Complete drawing on reverse side. Signed X TRW Date: OR PARTMENT USE ONLY Application Accepted by :Sj lydCu,,,A Date F11— Area Pit or Grout Inspection by Date Final Inspection by > Date Additional Comments: I Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOVNT REMITTED CASH RECEIVED 6Y DATE �yPERM17'No.EH 3-24 ! + EH 31-�tRFV.rias) 1 VV ILS