90-1842 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERI[I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION � y 1601 E. HAZELTON AVE. , PHONE (209)468-3420 l 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'Ord ce No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health 9ervices l` 1 et�'OIn Job Address _, • �i'�✓f�%OYl City Lot Size/Acreage �2s f Owner's Name _��iy9 /yAddress (/tc/ /►yfL Phone J�- tib--�" '7�Y � t"'/ 7'� -C�l ��d.Z Phone 7 Contractor_ Address License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑ DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SE K SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUt,TURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A _ONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom ❑ Manteca Dia. o xcavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy --Typ -of Casing ___ Specifications Il Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. QppAS ` I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump -H.P. State Work Done Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION INo septic system permitted it public sewer is available within 200 feet.) Installation will 1 Residence_ Commercials Other" Number of living units: bat'„ f bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No."Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/s1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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, 1 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:"1 certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applica m for alLrou4ed in c' ns. o plots drawing on r rse de. T Signed X Title: . Date: ( 9a FOR DEPARTMENT USE ONLY _ [� Application Accepted by Date / �� c )" Area `� l Pit or Grout Inspection by Date Final Inspection by�� "-�-=—� 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 CASH RECEIVED By DATE PERM17'NO. + EH 13.24IREV.1/e s) oU EH 14.26