90-2353 - 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 `ly IL � P 0 BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein de ,This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations , San Joaquin County Public Health Services. �� Job Address ��n�l� wA "tCr Cit � Lot Size/Acreage Owner's Name t)uL;L, Address�r�'��l" �1 _ Phone Contractors z4gt4"- Address/-1,72—VV&.•�•� Mie License No��?D6 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well C7 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 �Q Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('I Public (1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth �I I y �Eastern Surface Seal Installed b Repair Work Done Y Type of Pump„�Q" H.P. - State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth A it dzo, Depth Filler Material & Depth off ]- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I INo septic system permitted if public sewer is ( , available within 200 feet.) v A Installation will serve: Residence_ Commercial_ Other iO�N\ Number of living units: Number of bedrooms 4 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/size FILTER BED C) 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 '�v 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 applicantmustcall for all required inspections. Complete drawing on r arse side. Signed X_/x �► �� Title: Date: _!��r �� 1 oe FOR DEPARTMENT USE ONLY � —�� Application Accepted by Date 4 42 as Pit or Grout Inspection by Date Final Inspection Datl " 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 RECEIVED BY DATE PERMIT'N0. INFO CAn . EH -21(REV.t i n s) A [� _ �� EH Z�-M