91-1873 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 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 No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health S rvices. r `6 /f Job Address S v City Lot Size/Acreage �✓ Owner's Namega4�6-� Address - / r Phone ZZ Contraclor &42� Address / I icense.N01t 1?1--fttane TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYST M RE;PA ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSAUCTION SPECIFICATIONS F) Industrial ❑ Open Bottom ❑ Manteca Dia. f ell Excavation Dia. of Well Casing C':1 Domestic/Private ❑ Gravel Pack ❑ Tracy T Casing Specifications it Public 1-1 Other f� Delta eptlt of Grout Seal Type of Grout- Surf" / I I Irrigation �.Approx. Depth I I Eastern e Saul Installed by Repair Work Done L3 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material 8 Depth Depth Filler Materiel A Depth TYPE OF SEPTIC WORK; NEW INSTAL ION I I REPAIR/ADDITION 1 ) DESTRUCTION I ) lNo septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: fi Water table depth SEPTIC TANK ❑ Type/Mfg _E.yg. Capacity Zv v No. Compartments �} PKG. TREATMENT PLT. ❑ I Method of/Disposal ©y Distance to nearest: Well , Foundation I— Property Line LEACHING LINE Ll No. & Length of lines Tgtal length/size 2- i FILTER t3ED ❑ Distance to nearest: WEEI oundation 4 Property Line SEEPAGE PITS 11 Depth Size _ Number Of SUMPS L1 Distance to nearest: Well/ AL 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 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 for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The apptican must call for a quired ins ctions. Complete drawing on reverse side. Signed X ! 'Title: Date: 9- R DEPARTMENT USE ONLY Applicaon Accepted by Date- I Area 2— ��JJ�� Final Inspection Dace Pi or Grout Inspection tfy x � Date Additional Comments: (( Applicant - Return all copies to:" San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 FEE INFO AMtOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT No. EH 13.24[REV.rik5t / 7��Q j 4I E H 11.2E f l /e