SU0006453 - 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 BOR 2009, STOCKTON, CA 95201 D 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./ SFJob Address - , City Lot Size/Acreage Owner's Name / 7 A z� . i//f"/� Phone � IC Contractor S dress GO License No.4�e�Phone /�L TYPE OF WELL/PUMP: NE WELL O WELL REPLACEMENT ❑ DESTRUCTION E) Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE AGRICULTURE WELL-_---- --OTHER.WELL _P-M_5_LMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rt , � ! /r C] Industrial [T Open Bottom' ❑ Manteca Dia. of Well 2 Dia. of Well Casing Y Domestic/Private` }�1 J gravel Pack ❑ Tracy Type of Casing AW(n- Specifications I'1 Public n Other ' n Delta Depth of Grout Seal Type of Grout I I IrriOation dZApprox. Deipth �I I Eastern Su ce Seal Installed by � y / Repair Work Done ' -Type-of-Pymp_�aLGL�_ H.P. Sta�te/C�Nork Done pR/•LL— !l�L,LOnl Well Destruction O Well Diameter Sealing Material & Depth dl.R' 'TD r ,Depth, Filler Material & Depth 0 a im VPfP 'OW TYPE OF SEPTIC WORK:`-NEW YN STA LLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is ri 7Z_ available within 200 feet.) fes,f Installation will serve: Residence=' Commercial_ Other .c]r ivt 9 uriit3: Numtter of bedrooms Number of I �� i 1 _ Character of sox to __gepth of 3 feet: _ ' .�' j F�l Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments V PKG. TREATMENT PLT. ❑ ;`~ Method of Disposal I =-Di}t ,)CS 'to-nearest: Well F}iundation Property Line _ � .^ No. &Lien I \S LEACHING LINE�-,;\' � � gth of lines j _ Total length/siz \ � FILTER BED `. ❑- Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with!S in Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County i Home owner or licensed agent's signature certifies the following: "I certify that in the performance of hire worklor 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: ")certify that in the performance of the work for which this permit is issued, I shall ik`rlploy persons subject to workman's compensa- tion laws of California:" pp Complete drawing on raver fide. Thea applicant us - e fired i � Signed X j Title: ` l-1- --I Date: _aO 7,1 a F DEPARTMENT USE NLY I Application AcceQs�6 . Date ��,LCi�0- Area C/ Pit or Grout Inactio Date Final Inspection b Date J Additional Cortuments: f Applicant -;Return all copies to: San Joaquin County Public Health Services, Environmental Health PeTmf�/S-ePvir`es 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 NEE FO OUNT DUE AMOUNT REMITTED CKSN RECEIVED BY DATE PERMIT . EH 1341(REV. i n 5) 7 EH�1_28