SR0079974 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, 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 1862 and the Rules and Regulations of Ban Joaquin CountyPublicHealth Services. Job Addfess ///i�� 3Q0 Ale/ew �,N City�]�7f; Lot Size/Acreage Owner's Name ��Ayl� Arr_ Fpojo A� Address J44 Phone ContractorLGSC��t; /'�trL<<er�ta4uer Address LZLt�� e&rtd64�o113 LicenseNo,.Q �j Fnone-AfO`-222-207g TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well D PUMP INSTALLATION E3SYSTEM REPAIR ElOTHER ❑ Monitoring Well C] 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 r"V C'. Industrial ❑ Open Bonom C] Manteca Dia. of Well Excavation _ pia. of Well Casing Ll Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing Specifications r� F: Public C] Other 171 Delta Depth of Grout Seal Type of Grout V I I Irrigation AppfoK. Depth I l Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. I\., . State Work Done_ (� Well Destruction Cl Well Diameter Sealing Material & Depth n� Depth Filler Material'& Depth V TYPE OF SEPTIC WORK: NEW.INSTALLATION -REPAIR/ADDITION I I DESTRUCTION I (No septic system permitted if public sewer is L, 1 available within 200 Iest.l Installation will serve: ResAence,CL, Commercial__-__ Other Number of Irving units:I Number of.bedrooms_.2 Character of soil to a depth of 3 feet: Water table depth K SEPTIC TANK ;' Type/Mfg- O N Capacity 1 00 No. Compartments; PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well.5; Foundation /d Property Line /0 / LEACHING LINE CkNo. & Length of lines .2- gSTotal length/size r FILTER BED ❑ Distance to nearest:' Well �� Foundation Properly Line /D ' SEEPAGE PITS Depth 2 S_ Size Number �- SUMPS LI Distance to nearest: , Well 's Foundation 14 Property Line_/ate' 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 candies 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 Iowa of California." The applicant muKtIl for all requ ad inspections. Complete drawing on reverse sido,. ////Signed x � � Title:�� Date: �Z- FOR DEPARTMENT USE ONLY Q Application Accepted by 4{tea-AIXA� � -_Q• = Date � `� Area Pit or Grout Inspection by Date Final Inspection by a- ��fiv` Date l Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services - 1601 E. Hazelton Ave., P 0 Boz 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDrC" RECEIVED BY.. PATE PER fv0. IN f H NO. • EH 1`�IAEV.inti 51 F-F \.J� 1�_ ��`'� 1 I