90-925 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMENT ENVIRONMENTAL HEALTH DIVISION RECEIVE® 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 APR 5 1990 + pgUll XP RES 1 YEAR FROM DATE ED SAN ,10AQ N COi!.jNTY (Complete in Triplicate) PONME lA!_THSTR�/IC S - " ENVIRO�kMEP31-A1.HEALTH DiVtSION + 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 1$52 and the Rules and Regulations of San Joaquin County Public Health Services. ;. Job Address loll) E ej i�. City S4v-r1`4-,--%. Lot Size/Acreage n Phonk209 9SZ--0 0>5:7. N Owner's Name [.OYNI��t "— " ress 7g�� ' Pei-s4 rr' ! Contractor �rAddress `l� Licens�o. Phone _ rA�t+�� P Ig�h" TYPE OF WELL/PUMP: NEW ELL WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Wen ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 1 7 OTHER 171 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES` DISPOSAL FLO. PROP. LINE 1Q FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r� 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (I Domestic/Private Gravel Pack C] Tracy Type of Casing PSG I Specifications- — I') Public [-I Other n Delta Depth of Grout Seal ype of Grout L I I Irrigation .Approx. Depth I 1 Eastern Surface Seal Installed by I Repair Work Done U Type of Pump H.P. State Work Done — f Well Destruction ❑ Weil Diameter Sealing Material & Depth r Depth Filler Material 8 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet,) Installation will serve: Residence— Commercial — Other Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: Water cable depth Y SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments (� I PKG. TREATMENT PLT.C7 Method of Disposal F t Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines II" Total length/size FILTER BED ❑ Distance to nearest: Well ; " Foundation Property Line f SEEPAGE PITS 11 Depth Size Number SUMPS C! 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 in the periormance 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 applicant must call for all required inspections. Complete drawing on reverse side. � - I Signed X — �� Date: Z J �a Title: D M NT USE ONLY—woa+ Application Accepted by Date F U Area!_ tf i Date r Z D `7 0 Pit or Grout Inspection by a� — Date q Final action by f 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 AMOUNT DUE AMOUNT REMITTED H RECEiVEA 8Y DATE PERM17'fJO. INFO tEH13.24IREV.1/M51 EH S!-Ze