91-1638 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES qAM ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE IgJaUED (Complete is 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 i Joaquin County Public Health Services. 1 Job Address rQJ2-Z S- UJAGAJe\ RO City �oeklw Lot Size/Acreage M � Owner's Name R �tL R� M AC II A Address e Phone Contractor ''tet l n�' Address +!� &n1-GAJ AV C_ License No.244211% Phone'92��s TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 11 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION _%,.AGR(C-U:ARE WELL- OTHER WELL PITS/SUMPS { INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i` I L] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fa Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications'` F1 Public i-1 Other Cl Delta Depth of Grout Seal Type of Grout '"" \ l I ! Irrigation �.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P, State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth 4 � Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION W REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic system permitted if public sewer is r I available within 200 feet.) Installation will serve: Residence Z Commercial Other 1 Number of living units: _�_ Number of bedrooms i Character of soil to a depth of 3 feet: Abu p- _ 4 NAA OpAv Water table depth SEPTIC TANK. ❑ Type/Mfg _ Capacity. 1200 No. Compartments Z i PKG. TREATMENT PLT, C1 I Method of Disposal Distance to nearest: Well O�J___._ Foundation Property Line r LEACHING LINE ^Cl No. & Length of lines' f I/1�5 Total length/size fJ FILTER BED —0. ❑ Distance to nearest: Well Foundation Property Line ` SEEPAGE PITS Il Depth !2S' _ -Size _.? Number SUMPSLI"•Distance to nearest: Well ) Foundation Property Line r 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 reg6lations of the San'Joaquin County F j 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 signatures 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." r The applicant must call for all required i pections. Complete drawing on reverse side. t Signed X + Title: Date: ^t FOR DEPARTMENT USE ONLY lication Accepted by Data Area Pi r Grout Inspection bW/L Date Final Inspection by Date Z Additional Comments: l� tfP. 0� 7 Applicant - Return all copies to: San Joaquin County Public Health j Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INF Q AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. ♦ EH i4-20 .r/KSI I .Q D fL