91-0698 - Laserfiche WebLink

Home Browse Search

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 URRIIT EXPIRES 1 YEAR FROM DATE ISSUED_ (Complete in Triplicate) i 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 11 Joaquin County Public Health Services. I Job Address Z-) City 05S6"J%e) Lot Size/Acreage Owner's Name G y c jG i Address _ _ �"" Phone -contractor- ^��r" -e 4 - Address'_PCY �n�r �� '"`" License No�� r Phone-o'er a-=.4 I ` TYPE.OF WELL/PUMP:_ NEW WELL ❑ "µ'WELL REPLACEMENT ❑ =� DESTRUCTION ❑ Out of Service Well ❑ i PUMP INSTALLATION ❑ SYSTEM`R�PAIR CJ,- OTHER C3Monitoring Well r. DISTANCE TO NEAREST: SEPTIC TANK •• SEWER LINES -.,, .-6iSPOSAL FLD.- ` PROr. LINE FOUNDATION '^AGRICULTURE WELL L' " ER WELL"^'" -"• PITS/SUMPS _ INTENDED USE TYPE OF-WELL PROBLEM AREA CON8T UR CTION SPECIFICATIONS - --- - n industrial '❑ Open Bottom _2_, 0 Manteca_f Dia.�of Well Excavation Dia. of liVell Casing Cl Domestic/Private ❑ Gravel Pack x 0-Trady `-Type.o-f Casing Specificatiori5 FI Public i I Other fl,oelia." Depth of Grout Seal } Type of Gaut I irrigation Approx. Depth I I Eastern Surface Seal Installed-by w� f Repair Work Done 0 'Type of Pump H.P. ` State Work-Donee ----�' / f ` Sealing Material & Depth Well Destruction ❑ Well Diameter .,t i I Depth Filler Material b`Depth ; 1 TYPE OF SEPTIC WORK:: NEW INSTALLATION REPATADDITION l I DESTRUCTION I I {No septic system permitted it public sewer is M i i , available within 200 feet.l 1 installation will serve:' Residence Commercial_ Other Number',of living units: —1— Number of bedrooms _?* — Character of soil to a depth of 3 feet: _ So�eP t.rxle . Water table depthi { SEPTIC TiNK Type/Mfg Q -d•• L c Capacity,1` tl b` No.-Compartments PKG. TREATMENT PLT. 0 f ' :' -�Method-of-Disposal I1 x4 Distance to nearest: WellFoundation�^ Property Line QL S i LEACHING LINE P/ o. & Length of lines'l+nit 1 - �i0 ti. _: '' Tonal length/size r FILTER BED ❑ Distance to nearest: Well l f7 a Foundation _ Property Line _ _ R _SireSEEPAGE PITS 1 'I Depth r Nymber t1 i SUMPS tk<Distance to nearest: Well a'�djtion Property tine _ 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 peOormancd:of the work for which this permit is issued, I shall not I employ any person in such manner as to become subject to workman's compensation laws of Caiifornis:" Contractor's hiring or sub-contracting.signsture l certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ pardons subject to workman's compensa- tion laws of California." 1 ` The applicant must call for all required inspections. Complete drawing on reverse side. s� a ,� j Signed 7(_�.�,/.��r� __ /�,L[,�,c— _ Title: ,_ r/�-`�.rt,�" t Date: 13 A k fi DEPARTMENT USE ONLYI jr i Application Accepted by Date `,,7 � Area Pit or Grout Inspection by ate,, Final Inspection by Date Additional Comments: I Applicant - Return all copies to: San Joaquin County Public Health Services, Eavironmental-Reaith Permit/Services b t 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMi7•N6. INFO CASH - . EH t3-241AEV,rinse EH 34.26