90-3019 - Laserfiche WebLink

Home Browse Search

f APPLICATION FOR PERMIT ke SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES /00 ' ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PFaMIT EXPIRES 1 YEAR FROM DAJg 15giuED (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 > -fir"V_ City Lot Size/Acreage Owner's Name 1)if/4�OYV Address I b al' /l/. Jb e k L:4 Phone -IS-47-17 Contractor k,41? Address License No. ©4`rf Z- Ph o a + TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 'DESTRUCTION ❑ Out of Service Well ❑ ' PUMP-INSTALCATION-0 SYSTEM-REPAIR-til-— OTHER []—..-Monitoring,Well-[7. t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. I PhOP. LINE FOUNDATION AGRICULTURE WELL ! OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' n Industrial ID Open Bottom ❑ Manteca Dia. of Well Excavation Dia.,of Well Casing El Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing 7 " i Specifications #'1 Public I-] Other 11 Delta Depth of Grout Sea[. 4 ;-Type of Grout I I Irrigation —..Approx. Depth I I Eastern Surface Seal Installed by ` ' Repair Work Done 0 Type of Pump H.P. State Work_Done �. I Well Destruction ❑ Well Diameter Sealing Material & Depth, . l' Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public'sewer is YP�t7�c� .eytol SYaI^s— ' I available within 200 feet.) f Installation will serve: Residence 4, Commercial_ Othei Number of living units: __L_. Number of bedrooms �! ` Character of soil to a depth of 3 feet: 1*& K+ tt __ € fY ' Water.table depth ' a-- ' SEPTIC TANK. 0"'Type/Mfg r_-.d,dLe.}-c_A=_ Capacity -No. Gompartrrtents � "PKG. TREATMENT PLT. ❑ '; -Method of Disposal ' Distance to nearest: . Well 7S Foundation la Y Properly Line LEACHING LINE No. & Length of lines ..-- - . O Tofal length/size' lool % p ._ FILTER BED `" ' . t ❑ Distance to nearest. Well_� Foundation r,35 Property_Line +700 SEEPAGE PITS I 1 Depth Size SUMPS LI Distance to nearest: Well Foundation ` %� ` Property.Line DISPOSAL PONDS ❑ I hereby-certify that I have prepared this application arid that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County I ..� „ • '` I �. ' t=� § Homeowner or licensed agent's signature certifies theJoilowing:,,Ll 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 foilowing: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of Calif nia." j - 4 , The applicant ust call for re 1redns"iplions. Complete drawing on verse side. '- i Signed Title: t fir- Date: /IA# d" l � OR DEPARTMENT USE ONLY u{ Application Accepted by &C%AP-�L rf*n A.& - - --Date. —A- D a Pit or Grout Inspection by Date Final Inspection Date/ Additional Comments: } ' e r� C t Applicant - Return all copies to: San Joaquin County Public Health f Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIVr�NO. + EH13.2 THEY.tias)EM 14-26 L `� 0_6 V�__l I _) .1v