91-1252 - 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 REMIT E%P#RT_sSS 1 YEAR FROM 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 CountyPublicHealth Services. ( I '__ Lot Size/Acreage Job Address � n � �� w ^ j1�15c`}s'f e� ��} City_ � ' Owner's Name 1&(YT 't-Address117L111:,= Phone water Ju I Publics stem ---- --------------------------------- PPY� y ❑ Community system Private ❑ Depth to Water Table ---<- ft. Character of soil to.a depth of 3 feef: Sand [-] Gravel I—f S �I __ �/ IYYt Ut- WEU LL/r' MFNEW WELL NEWELL LJ WEL %61I CC9RENT LJrl}.. D R1.2T10fa Ll Out br bervice Well Ll j _v PUMP INSTALLATION ❑ SYSTEM.REPAIR ❑ -OTHER Cl—. Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS',_ i t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f_-] industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ; Ca Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (1 Public 1-1 Other 171 Delta Depth of Grout Seal Type of Grout I I trrigation __-._.Approx. Depth l I Eastern Surface Seal Installed by Q Repair Work Done U Type of Pump r-- H.p._ State Work Dane�. Y Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material A Depth - - TYPE OF SEPTIC WORK: NEW'_INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I'1No septic system permitted if publiasewer is I available within 200 feet.1 t- Instillation will serve: Residence Commercial �_ _Other Number of living units: Number of bedrs Character of soil to a depth of 3 feet: A� bL _ i Water table depth s SEPTIC TANK ❑ Type/Mfg ' +mss '-Capacity No. Compartments PKG. TREATMENT PET. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines __ L - 1 t 7 _ Total length/size FILTER BED ' ' ` � �i 1' 'jGF�Distance to nearest: Well Foundationt Property Line �d SEEPAGE PITS 11 Depth Sire __ Number SUMPS Ll 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 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 must call for all required inspections. Complete drawing on,reverse side," s Signed X Title: f fits r[ G r r, .__ 'Date: g I FOR DEPARTMENT USE ONLY Application Accepted by 1 Date s 1 11 Area Pit or Grout Inspection by Date Final Inspection by Dates ZZ Vet 4 Additional Comments: F I Applicant - Return all copies to: San Joaquin County Public Health } Servilces, Environmental Health-Permit/Services --- 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASK11 RECEIVED BY PATE PERM17'NO. EH 13-24 IREV. /Ksl I C/� I�'Q� •.' EH