91-1384 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PPR_!_fIT___EXPIRES 1 YEAR FRQM PATE ISSUIM(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 Or nce No. 549 and 1$62 and the 'Rules and Regulations of San Joaquin County Public Health Services. i Job Address Q p City S Lot Size/Acreage Owner's Name bosLlAddresses J Phone Contractor " me___Addres " dLe License No- Phone TYPE OF WELL/PUMP: NEW WELL lop„ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ i PUMP INSTALLATIONlQ-1., SYSTEM REPAIR' OTHER ❑ Monitoring Well L-3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION t 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 '>Oomestic/Private ❑ Gravel Pack ❑,lTracy Type of Casing. Specifications 1 ) Public El Other n Delta Depth of Grout Seal Type of Gro Irrigation —.Approx. Depth )Eastern Surface Seatinstalled by Repair W ark Done ;0 Type of Pump H.P. __ :5_ 4______ State Work Don G-r Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Piller Material 8 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is 1 available within 200 feet.) installation will serve., Residence_ Commercial_ Other Number,of living units: Number-of bedrooms — Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ vfy �, ,� � } ) Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines } Total length/size FILTER BED 11 Distance to nearest: Well Foundation Property Line r y SEEPAGE PITS I I Depth Size _ Number SUMPS LI 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 s 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 work man's.compeiisafion--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 com nsa- tion laws of California." The appli u call for all required in Ctions., omplete drawing on re se side. d Signed X Title: �p Date:. --� F ARTMENT USE ONLY Application Accepted by Date Are ,f Pit or Grout Inspection by Data Final Inspection by Date z-! 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 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. + EH 13•24IREV.7/x51PP .c I ( 1 '4 t `EH 742E [�j