90-2123 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �Z—rho lv 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 �sf I waft Pv& PEMIX EXPIRES 1 YEAR FROM DATE ISSUED (Complete iu Triplicate) Application is hereby made,to San Joaquin County for a permit to construct end/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 Service . Job Address � Cary Lot size/Acreage Owner's Name ,f S �� e Address -5 '- Phone z v 7 CI 7 Contractor Address ' �( `'License No.�� Phone +`) � TYPE OF WELL/PUMP: - NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ \ PUMP INSTALLATION ❑. SYSTEM REPAIR ❑ OTHER ❑ 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 11 Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing to Domestic/Private ❑ Gravel Pack M Tracy Type bf Casing Specifications i'I Public HCl Other 1=1 Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth l'l Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump State Work Done Well Destruction O Well Diameter. Sealing Material Depth i Depth Filler-Material & Depth I TYPE OF SEPTIC WORK: NEW INSTALLATION I I-•REPAIR/ADDITION IV DESTRUCTION I 1 1No septic system permitted if public Sewer is available within 200 feet.) - (� Installation will serve: Residence Commercial A Other' �J Number of living units: Number of bedroo�m�j - Character of soil to a depth of 3 feet: ��7 �— Water table depth i SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines - Total length/sire � FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS Al Depth Size l -- Number SUMPS 0 Distance to nearest: Well Foundation Property Line 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 i rules and regulations of the San Joaquin County - - "1 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 far which this permit is issued;,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all to a Inspections Complete drawing on reverse side, Signe TJAA]JOR tle: Date: f� i EPARTNFENT USE Application Accepted by Date 6 Area Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health - a Services, Environmental Health•Permit/Services- - 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT Rt1E AMOUNT REMITTED. CASH �RECEiVEp BY DATE PERMI7'NO. ! i EH 17-24 IREY.1 N 51 I EH 5�•2e p,�