90-3273 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION J� 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P p�" P O BOR 2009, STOCKTON, CA 95201 PERMIT 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 Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address o City hot Size/Acreage Owner's Name Address Phone Contractor + GAddress LicenseNo Phone g " TYPE OF WELL/PUMP: + NEW WELL ❑ -WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well D -- PUMP INSTALLATION.0 SYSTEM REPAIR ?;S_ — OTHER-0 ,-- Monitoring Well ❑ 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 L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1Xr Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public CI Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. DepthI Eastern 5 ace Seal Installed by Repair Work;Done �K Type of Pump , ' H.P. Z State Work Done P Welt Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feat.] Installation will serve: Residence T Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg t Capacity No. Compartments PKG. TREATMENT PLT. ❑ ti ,a ;''S Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest:x� Well � Foundation Property Line rt SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ � t 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 signaturXe certifies the following; "I certify that in the performance of the work for which Phis.permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ,; The appli call for all required 02ectio ompt a drawing on. a side. Signed X Title~ Date: len/i; (7�4 F ENT;USI; ONLY Q Application Accepted by Data �^— "�� A a Pit or Grout Inspection by Date Final Inspection by Datf 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 IFEEO AMOUNT DUE AMOUNT REMITTED CK 11 CASH RECEIVED BY DATE PERMIT'IV^0O.7 . EM 13-24IREV.$/"5) �61 0-0CAL E1414-26 V''