SU0004606 SSCRPT - Laserfiche WebLink

Home Browse Search

,b 4. APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 ' P O BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 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 vork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and x1862 and the Rules and Regulations of San Joaquin County9Pubblli,�c{ Health Services. �..{.. ��G-// / / Job Address / / /-� E' J,g�,�� z +J' City Lot Size/Acreage / C///Is- 1 Owner's Name MR. Es,pa,dei S Address6O�" � Phone / //6S ` Contractor t�rI05S / t4M/3 Address Ate• 1-1✓140J0J A174P License No. 7.7— Phone ��oq TYPE OF WELL/PUMP: , NEW WELL ❑ WELL REPLACEMENTF DESTRUCTION I.Pr Out of Service Well Ell 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 ❑ Industrial Ope� ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications _ I'l Public 1-1 Other F1 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_ Well Destruction Well Diameter Sealing Material E Depth 129 .-.<-4 _ Depth Filler Material d Depth (` TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is w available within 200 feet.) Installation will serve: Residence_ Commercial_ Other R` 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 PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number h SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 cenifies 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." Contractors 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 applic nt catcall for al iced inspections. Complete drawing on reverse side. Q Signed 6 �� -�� Title: Date: (\�L OR DEPARTMENT USE ONLY mob' A Application Accepted by Date � Area b 1 1•- Pit or Grout Inspection by Data Final Inspection by Data �' 42_ Additional Comments: — Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hatelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO 6V ^/AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE ��c�ssssPERMIT'NO. ,�. EH 1324 ISEV.rind /)r �p �V I� ' 12 ./ / �"• / EH:420 I