SU0005915 - 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 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDcoply(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 Co ty Ordinance No. 549 and 1862{nd the Rules and Regulations of San Joaquin County Public Health Services. 9 Job Address Dn p g 'PI. City Lot Size/Acreage Owner's Name z'7-n 1 r Phone Contractor Address h License Nor Phone Q TYPE OF WE L/P MP: NEW WELL ❑ WELL REPLACEME ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public I1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ C Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TALLATION REPAI TYPE OF SEPTIC WORK: NEW INSR/ DDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 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 Ir Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well / b f� Foundation_V_ Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest.- Well ( a n�- Foundation �_ Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well _L_1nZ'Z�-Foundation_ __ Property Line DISPOSAL PONDS Cl I hereby cond>LIIHI 1tiave 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 m t call a It is uired i ctio S. Complete tire '. g on reverse side. Signed itle: (-+'-7/J Date: t Al FOR DEPARTMENT USE ONLY �_ ! - e(- Application AApplication Accepted by _ I /. Date Area z Cit or Grout Inspection by�� ate�7 Final Inspection by �//�!f r Date/-2 Z 9� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT NO. EN 1114(AW.1115) lowI !2 © ' 1 EH 1�