91-0950 - 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 QED - IComplete 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. Job Address Lot Size/Acreage /'_ ! Fft,C m.s_ Address t , -IS 1. /atT G'!s+ Phone�� Owner's Name _ Contractor N e �suC. Addres550 ox S S License No. h ne �� TYPE Of WELL/PUMP: NEW WELL 11 WELL REPLACEMENT 1-1DES RUC ION L_1 out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER -� Monit r)ng Well {� r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LI NT FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE Of WELL PROBLEM AREA .CONSTRUCTION SPECIFICATIONS O;) Ci Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing (` FI Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing Specifications O FI Publicn Delta Depth of Grout Seal Type of Grout /4ENTd.r/if -- d I i Irrigation S-70 Approx. Depth 1 I Eastern Surface Seal Installed by ,cKrr Repair Work Done 0 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 REPAIRIADDITION l I DESTRUCTION i I INo septic system permitted if public sewer is available within 200 feet.I - Installation will serve: Residence— Commercial_ Other �J Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity-- No. Compartments , PKG. TREATMENT PLT. 0 Method of Disposal �(! Distance to nearest: Well Foundation Property Line i LEACHING LINE D No. 8 Length of lines Total length/size FILTER BED Ci Distance to nearest: Well Foundation Property Line - 4 SEEPAGE PITS 11 Depth Siz6 Number SUMPS { l Distance to nearest: Well Foundation Property Line DISPOSAL PONDS L7 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 raguiations 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 inspections. Complete drawing on reverse side. F Signed X Title: Date: FOR DEPARTMENT USE ONLY ;2 G Application Accepted by Date _ Area d` �/ _ Pit or Grout Inspection by Date Final Inspection by ' Date Additional Comments.- Applicant omments.Applicant - Return all copies to: San Joaquin County Public Health Services, 3rnvironmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009. Stockton. CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE Pf RMiT'NO. INFO �yy� �/� . EH 13-24IREV.I/as) o `VZ?(�s 000(y/r ,ay'[/ f 14.26