SU0013688 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERH I T .p SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i. ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. PHONE (209)468-3420 ;i P 0 BOX 2009, STOCKTON, CA 95201 ll PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i. 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 PublicHealthServices. Job Address LO� w City Lot Size/Acreage Ib Owner's Name r , o Address7�a/ Q 2r, 0 Phone OCL-?, 1 ri Contractor ( 1 llK Address�Q,,R, _ 7 License N Phone TYPE OF WELL/PUMP: �I NEW WELL ) WELL REPLACEMENT ❑ _ DESTRUCTION Cl Out of Service Well -q PUMP INSTALLJTION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring/Well— DISTANCE TO NEAREST:-SEPTfC TANK-1419r0' _SEWER LINES, DISPOSAL FLD. PROP: LINE/So .._._FQU-NDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS I. — Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private LI Gravel Pack n Tracy Type of Casing 5,13 Specifications fF! Public [ Olper Delta Depth of Grout Seal �( T p of Grout(_-c_Y►-�'1 I Irritgation C90-10 Approx. Depth t I I Eastern Surface Seal Installed by I v� Repair Work Done U Type of P' um I� H.P. State Work Done Welf Destruction ❑ Well Diameter Sealing Material & Depth - Depth Filler Material & Depth `' r TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION ! I (No septic system permitted if public sewer is C _ !I available within 200 feet.) Installation wilt serve: Residence— Commercial Other I Number of living units: Number of bedrooms :.. I t Character of soft to a depth of 3 feet: —Water table depth #SEPTIC TANK ❑ -Type/Mfg Capacity-----------.!-- No. Compartments IPKG. TREATMENT PLT. ❑ !' Method of Disposal Distance to nearest: Well Foundation Property.Line , r a LEACHING LINE Cl No. & Length of lines _ Total length/size.- FILTER BED Ll Distance to nearest: Wel! _ Foundation _ Property-Line_ k SEEPAGE PITS I I beplh Size Number SUMPS LI Distance to nearest: Well Foundation s Property Line DISPOSAL PONDS ❑ 'i - I hereby certify that l have .prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stat rules and regulations of the San Joaquin County e laws, and 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,'f 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,,l shell employ-persons.subject_to.workman's compensa- tion laws of California-" — The applicant must call for all required inspgi�tions. Complete drawing on reverse side. Signed Title: C G Date: I: R OR DEPARTMENT USE ONLY Application Accepted by C�7�-�I� G a �� 2 Date Area Pit or Grou Inspection by D t / u J Final Inspection by ate 3Z _yQ 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 f£E AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'N0. EH A-20IREV.�iMS, I/� _ 116a EH 2�•2a 3'V r O� �,� � / /�/ �/7 //