90-1711 - Laserfiche WebLink

Home Browse Search

F APPI I CAT IPN FOR PERM I T 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 E%PIRES 1 YEAR FROM DAZE ISSUED Pep,_tV, (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'P7ubclic HealtZ pe ea.'/ Job Address Q50-- 7_� P City C Lot Size/Acreage r C ,- Owner's Name Address Phone Contractor License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ 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 CONS TRUCTIOWSPEC.IFICA TIO NS N ❑ industrial . - K-----0--Open-Bottom-❑-Manteca Dia.-of-Well-Excavation -- Dia: of Well Casing XDomestic/Private ❑ Gravel PackF L1Tracy Type of Casing _Specifications Il Public I-1 Other f1'Oelis """ [Ye'pf _of Giaut Seal,-__ Type of Grout I ITlrrigation _Apprak`Depth I I-Eastern �� 'Surf a Seal Installed by Repair Work'Done . ' p pType of Pump H.P. State Work Done Well Destruction "❑3 WallDiameter • 4 Seali trial 5 Depth : e r Depth - Filler Material & Depth e h \, TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted if public sewer is r { available within 200 feet.) Installation will serve: Residence T Commercial_ Other Number of living units: Number of bedrooms ._. Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK. ❑ Type/Mfg' Capacity____4 # No. Compartments PKG. TREATMENT PLT.-0 > ...% t }vy .a.•4L I W w Method of Disposal .p w Distance to nearest: Well - foundation f Property Line r n LEACHING LINE ❑ No. & Length of-lines - k s Total length/size FILTER BED CI Distance to nearest: Weil Foundation Property Line SEEPAGE PITS 1 1 - Depth Size Number SUMPS L) Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I ; 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-contacting signature canifies the following: "I 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 appli ust call for all requir inspec ' ns. Co plate drawing on r e side. Signed Title: Date: 914 FOR DEPARTMENT USE ONLY Application Accepted by Data - Area Pit or Grout Inspection by Date Final Inspection by Date 3 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 INFO AMOUNT DUE AMOUNT REMITTED BASH RECEIVED OY DATE PERMIT'NO. • EN 13441REY.rixst (� EH