SU0004747 SSCRPT - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT F,` SAN JOAQUIN COUNTY PUBLIC HEALTH ORVICES > ENVIRONMENTAL HEALTH DIVISION NOW 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 B / PERMIT EXPIRES I YEAR FROM DATE ISSUEDylltAaw .ITc (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. 5119 and 1862 end the Rules and Regulations of San Joaquin County Public Health Services.'./ , Job Address 7 o_q ---V� n�' City 6L_ Lot Size/Acreage ' �m7s.� Owner's Name hA'QJC Address Phone Contractor Zc —Address .Z.f�To p' �, �` License Nile " Phone 3y�/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well LT DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P LINE FOUNDATION AGRICULTURE WELL OTHER WE L PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP ATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of cavation Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack ❑ Tracy a of Casing Specifications I'I Public (I Other fl D Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I Eastern Surface Seal Installed by --� Repair Work Done U Type of Pump H.P. State Work Done _ J Well Destruction ❑ Well Diameter Sealing Material d Depth C Depth Filler Material i Depth S TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I:1J^o septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: _ Number of bedrooms Zts 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. & Length of lines Total length/size f FILTER BED - ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS It Depth Size Number _ SUMPS LI Distance to-nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify 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 subcontracting signature certifies the following: "1 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 st call for all required in Wititions. Complete drawing on reverse side. f Signed ) "' - Title / - ( Date: `' �O FO EPARTMENT USE ONLY I Application Accepted by Date � � ai Area Pit or Grout Inspection by Date Final Inspection l Date-- Additional Comments: — Applicant – Return all copies to: San Joaquin County Public Health _R Services, Environmental Health Permit/Services �^ 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 EE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 13-24 vn 5) EH'A — V, V