91-1574 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 F. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 k , PERMIT EXPIRES 1 YEAR FROM DATE 19SUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This 4 application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. e' Job Address K�€ City d rCAC1b& Lot Size/Acreage /n, m-o Q'r Lr:.`" 5.9 � Q� �5'�fiSY X2,0 Q.�'' �J1D , Owner's Name Address Phone r _ Contractor Address License License No.,�42�5V.3 Phone f 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t fa Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing f Specifications I'1 Public I:1 Other 11 Delta Depth of Grout Seal 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 Wofk Done ^J Well Destruction 0 Well Diameter , Sealing Material & Depth W 21 AC,t Depth Filler Material & Depth .S(E&2 Vlea TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION i l (No septic system permitted if public sewer is rte} available within 200 feet.] I Installation will serve: , Residence— •Commercial Other (� a Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 4 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ f N __ Method of Disposal Distance to nearest: Well •Foundation Property Line 4 LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest Well Foundation Property Line t SEEPAGE PITS 11 Depth Size Number ` SUMPS Ll 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 sub-contracting signature cartifies 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 Il for all required irtspeJaions. Co tete drawing on re se si Signed L/ Title: Date: /'w ~26^ ` 1 DEPARTMEfVT USE ONLY Application Accepted by _ �hw� 1��,al�J�wd..� ____ _ _ __ Date Area Pit or Grout Inspection by Date Final Inspection byy ,1!y Data 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 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH 41 �RAECEEIIVED BY DATE PERMIT'NO. . EH 13.241REv.iinsi � �.� 4 f z- r _ 711 EH i4•Ze "1 [ I t