SU0006536 SSNL - 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 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 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 Joaquin County Public Health Services. Job Address i`% j ' j L'�I� F %�L` %1 'f City,l�y� / Lot Size/Acreages" ! _ Owner's Name l/,/r' .Y'f Vis; r �,rf✓.c Address /.i 4. /t a{r: eel{ }'�: Phone Contractor C "'✓C Address l f'!,` License No.-1(' Phone TYPE OF WELL/PUMP: .i NEW WELL ❑ WELL REPLACEMENT ❑ 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 F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing P Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public (1 Other rl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth SI Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ijIr REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence' Commercial_ Other #�I Number of living units: —I— Number of edrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg 'r L- x '-e- Capacity l G=i'4- No. Compartments Z_ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well //C Foundation 40 t Property Line k� > y. LEACHING LINE 0--"No. & Length of lines Z•.S �� Total length/size FILTER BED ❑ Distance to nearest: Well �U f Foundation ` Property Line - r SEEPAGE PITS lid'Depth : ' Size -i tr' _ Number 3 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 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,must,call for all requir9d ins ctions. Complete drawing on reverse side. Signed X_ // �' Title: ly 4ci %✓i Date! FOR DEPARTMENT USE ONLY Application Accepted by Date ^ l� —�U Area L / Pit ar Grout Inspection by > L� Date_ I S`� Final Inspection by kh a C� Date 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 CK INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT NO. EH 13-24(REV.iinsi IF1 ! i U ) 3 3'_ � A /�, ��1 ` � r1� _.2 l} EH A-26 1 71 ! �+'t