90-937 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT i rP -y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES as ' ENVIRONMENTAL HEALTH DIVISION q 1601 E. HAZELTON AVE. , PHONE (209)468-3420 NSW y P O BOX 2009, STOCKTON, CA 95201 g , PERI[IT 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. Job Address �- �'f ! City ' -,LotrSize/Acreege Owner's Name Address _ Phone Contractor J C A? Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER O Monitoring Well O i 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 F_1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public 1-1 Other n Delta Depth of Grout Seal Type of Grout t I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by" Repair Work Done 10 Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth s Depth f Filler Material & Depth (� TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION 1 I DESTRUCTION INo septic system permitted if public sewer is y' available within 200 feet.) Installation will serve: Residencef_ Commercial— Other S Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: # Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments LA PKG. TREATMENT PLT, C7 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ , r 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 taws of California." The applican m call for all re aired ' s coons. C mplete drawing on reverse side. / + �d Signed Title: _41 lf.-_/.�e; Date: F. DEPARTMENT USE ONLY q l Application Accepted by Date 4() Area b Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services w 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. . EEH1443 - IREV.rin51 ^��y aJ•V � L��vN �, T /� - 9 }; I