91-0931 - 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 BD slog e7aeb°r— (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 Job Address ��N a 1 2 'L P Y� -�� City � J Lot Size/Acreage Owner Name � E'`Z Address C>ot W 1_ul Phone IX Contractor ::> k Address License No. Phone 4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION AOut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 Cl Industrial ❑ Open Bottom M Manteca Dia. of Well Excavation Dia. of Well Casing 1.1 Domestic/Private 0 Gravel Pack L3 Tracy Type of Casing Specifications F] Public Cl Other n Delta_ Depth of Grout Seal.- Type of Grout + I I irrigation _� 'Apprdx.'Depth I i Eastern T Surface Seal Installed by Repair Work Done (J� Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material 6 Depth Depth Filler Material b Depth o TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADOiTION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet. Installation will serve: Residence— Commercr _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Capacity N(;)_ PKG. T PLT. ❑ Method of Disposa - Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED C1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ it 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 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 required inspections. Complete drawing on reverse side. 111--is— � � Dy J Ww-A-, Date: / `i L / Signed X ��i�' /�f� S .rpt, ; '`� Title: d- R DEPARTMENT USE ONLY t i_ Application Accepted by !� Irv► + }�,e,A � Date T S A Area Pit or Grout Inspection by a Date Final Inspection by ) 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 INFO EEE MOUNTDUEAMOUNT REMITTED K * RECEIVED BY DATE J d4z t�s�I gPE/RMIT'NO. l r EH 13-2/(REV.i/MS1 U © ' ® .V V �'+l" / ■ ` o EH N-26