90-755 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT � wfl SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 No P O BOX 2009, STOCKTON, CA 95201 PERI[IT 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 Services. f L / Job Addresses �� 'V Z� City �� Lot Size/Acreage Owner's Name ! Address (n Lz �J r� Phone Contractor.&A rG+y �rV Atld ess .0 ense No. hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEt4VO DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C.1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 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 17 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i"1 Public fl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION ef INo septic system permitted if public sewer is j n available within 200 feet.) V 1 Installation will serve: Residence_ Commercial_ Other v ✓ Number of living units: Number of bedrooms 7,.,.-��i/ �� y`�/ Character of soil to a depth of 3 feet: q1�,ate*able pth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C) No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 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 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 applicant must call for all required in ns. Co �ete dra i g on reverse slider.. Signe tFO itle: �'�`�` Date: � J + EP'��RTMENTUSONLY Application Accepted by 3 Date Area Pit or Grout Inspection by Date Final Inspection by ` Date O 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 FEEIN 0 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. _�� . EH 13-21(REV.�i n S) EH,..2, v�' `Z/9