90-2448 - Laserfiche WebLink

Home Browse Search

APPLICATION V4@R PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t ENVIRONMENTAL HEALTH DIVISION IN, C ACHADO . 1601 E. HAZELTON AVE. , PHONE (209)468-3420' ZM47 N.JeCDOa Q p", s/ P O BOR 2009, STOCSTON, CA 95201 Stockton, Callfornla g 3 PEW215 EXPIRES I YEAR FROM DATE ED (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. C Job Address �C I �a ,�O � City ►J� 4--Mt Size/Acreage Owner's Nam tt 0- :5y��—� Address %0.06 - 'Q- Phone LContractor X-C, Address [-� w License No.3 2 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER p Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Se Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications ` I'1 Public Ia Other n Delta Depth of Grout Seal Type of Grout 1.J I i Irrigation w-Approx. Depth i I Eastern Surface Sedl Installed by a Repair Work Done X Type of Pump H.R. __g2= State Work Dona XJ2 =4/_ -- Well Destruction ❑ Well Diameter 1.Sesiling Material & Depth Depth Filler Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/,ADDITION I } DESTRUCTION t I (No septic system permitted if public sewer is �} available within 200 feet.) 1 installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: d Water table depth SEPTIC TANK. ❑ Type/Mfg t Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS _ 11 Depth Sire _ Number SUMPS Cl 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 rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that-li 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 perlormance of the work foi which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Ca' nia." f The a _' ant st call for all require $Pett' S. Cc late drawing on re side. 9 (' Signed X Title: Date: DEPARTMENT USE ONLY Q 4 Application Accepted by _ # Date y�1Z 31 Area Pit or Grout inspection-by - Date F -Finil inspection by_____ __ Date J 3 J I Additional Comments; Applicant - Return all copies-to: �$an.Joaquin County Public Health • Services, Environmental Health'Permit/Services I 1601 E.°Hazelton Ave'., P 0 Box 2009, Stockton, CA 95201 t FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERM17'NO. . EM13-24(14Ev.I/as) -2 10 EH A-26