90-1516 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN .COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , 'PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT E%PIRES 1_YEAR FRS 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-vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. i' (� t Job Address 3 -7 � 54" 1 Ail' AEL Av City( "mot Size/Acreage � l Owner's Nam.1 ")cK. ✓ L { "- K -- Address l�} /V ' EOU PA L2-_ Phone 3 If CDntraclor P L/L 7 0 Al. > Address _A;X License No � Q Phone?a TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-0 DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION 11 f SYSTEM REPAIR'❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE �- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL r 'PROBLEM AREA~ CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ° Specifications I'1 Public , fel Other 171 Delta Depth of Grout Seal Type of Grout t I Irrigation Approx. Depth l I Eastern Surface Seal Installed by r Repair Work Done 0 Type of Pump H,P. .State Work Done Well Destruction ❑ Well Diameter Sealing Material ✓F Depth Depth Filler Material &.Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I DESTRUCTION I I fNo septic system permitted if public sewer is available within 200 feet.h Installation will serve: Residence X_ Commercial— .Other Number of living units: --I— Number of bedrooms��f Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK. ❑ Type/Mfg 4 5 i6" Capacity No. Compartments PKG. TREATMENT PLT. ❑ % Method of Disposal Distance to nearest: Well Foundation Property Line . �. ¢ LEACHING LINE _ No. & Length of lines Jotal length/size FILTER BED Distance to nearest: Well _'"Faundation�,=___._. Property Line k SEEPAGE PITS . Depth - 5 Size F Number _ SUMPS Distance to nearest: Well� Foundation8;0 Property Line DISPOSAL PONDS ❑ r , 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 cenity 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, t r The applicant mustc or re -ad'i pections plete drawing on reverse side.} Signed X C Title: r Date: r /] FOR DEPARTMENT USE ONLY r Application Accepted by d ��,�! Xfy� Date 40 Area Pit or Grout Inspection b Date Final Inspection b � Date Y p Y - 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 r 1FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EM17211REV.v/N51 ., -7o 11 3 70 / EH 41.2E