91-0860 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT CANNED L :b SAN JOAQUIN COUNTY PUBLIC HEALTH SER VICE � ENVIRONMENTAL HEALTH DIVISION ll 1601 E. HAZELTON AVE. , PHONE (209)468-3420 Zw� P 0 BOX 2009, STOCKTON, CA 95201 EEMIT EXPIRES 1-YEAR FRP-M DATE .,ISSUED (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 �� j C {V City ' 42�y Lot Size/Acreage c ' }y_ Owner's Name CI O ock Address A :$nA VI �t�i�lyt �T` fie` Phone Z0i F1101- Contractor��_I �� Address + G ` x--m License N T= �n,"IS Phone O. b TYPE OF WELL/PUMP: NEW WELL WELL.REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Wel DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE r lL FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ 3g 1:611 r5 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation A Dia. of Well Casing �+n 0 Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing{Ove _ Specifications i'I Public 1-1 Other 11 Delta Depth of Grout Seal . 2_32h Type of Grout mai 1 1 lrrigauon _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P.Sealing ¢1 $tate Work Done Well Destruction ❑ Wall Diameter ng Material & Depth ec iC)/ ,r t>"11041t 0-3�L tttt Depth ' ^ Filler Material & Depth QL�t__1 c9✓t��rG� Z�2 50.n 33 5Z) \1y TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is Q available within 200 feet.) Installation will serve: Residence_ 'Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments"' PKG. TREATMENT PET. ❑ Method of Disposal Distance to nearest: Well Foundation Pr oparty Line , LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED (1 Distance to nearest: Well Foundation Property Line 10 I�A FL SEEPAGE PITS 11 Depth Size Number [� SUMPS LI Distance to nearest: Well Foundation Property Li I '..` e s �1� DISPOSAL PONDS ❑ +K iL:� J1 � I hereby certify that I havere orad this application P p pp kation 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 ust call for II required inspections. Complete drawing on reverse side. Signed x 5&_ 6-e Ilt sr` Title: /w Date: i FOR DEPARTMENT USE ONLY i I Application Accepted by Date Area i Pit or Grout Inspection by Date .Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services II 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 ` FEE AMOUNT DUE AMOUNT REMITTED RECEIVED By DATE PERM17'ND. INFO (](� CASH . 12 TREY. E.H 14-28 r i x 51 .i•S`-�� ']�� tQ /�� (1i! /y J�� 4