SU0013688 - Laserfiche WebLink

Home Browse Search

II APPLICATION FOR PERMIT 'V! I �I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 guur'r EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) f P.pplication 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. r, 3 �cl City L-&- Lot Lot Size/Acreage Job Address I - Owner's Name �! Address QW- ContractorC- Icl � Phone Address _ License No. Phone TYPE OF WELL/PUMP: II, NEW WELL ❑ _ WELL REPLACEMENT LI DESTRUCTION F1 Out of Service Well ❑ PUMP INSTALLATION ❑ , SYSTEM REPAIR C' OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST:^SEPTIC TANK-- -- _SEWER LINES T DISPOSAL FLD. PROP. LINE ^' FO,UNOATION_ ..AGRICULTURE WELL- OTHER.WELL _PITS/SUMPS Y INTENDED USED TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1.1 Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications i1 Public :-1 Other 1-1 Delta Depth of Grout Seal Type of Grout t 11 Irrigation _�I Approx, Depth l I Eastern Surface Seal Installed by. r Repair Work Done L1Type of Pump H,P, State Work done Sealing Material i Depth Welt Destruction ❑ Well Diameter 1J " Filler Material & Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION 1 1 Wo septic system permitted if public sower is �I available within 200 feet.) C Installation will serve: Residence Commercial_ Other Number of living units: f` Number of b drooms q: - Character of soil to a depth of 3 feet: Water table depth "SEPTIC TANK '; (/Type/Mfg Capacity.Al --No.-Compartments t.PKG. TREATMENT PLT. E) I / Method of Dispo)al Distance to nearest: Well `1[CLT_ Foundation �� Property Line 1160 di. LEACHING LINE hQ 'No. & Length of lines � J_- �� Total length/size yll FILTER BED FJ Distance to nearest: Well I b 6t Foundation / 10 /" ..Property Line_ II SEEPAGE PJ�S `Depth s Size Number SUMPS El IiDistance to nearest: Well 1 �O Foundation . /� Property Line �d0 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 subcontracting 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." 1 The applicant must call for all)re wired in pections. Complete drawing on reverse side. �j Signed Title: �LV�L Q��" Date: --- Ip F RTMENT USE ONLY r Application Accepted by Date "�- Area 19 or Grout Inspection by Date Final Inspection by DatZY t � Additional Comments: 'i Applicant - Return all copies to: San Joaquin County Public Health 17 Services, Environmental Health Permit/Services 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 9 RECEIVED By DATE PERMIT-NO. INFO 11 1 CASH EH 13-21 f9fV.tin5t EH t4-2e D 50L1O^I1 ..