90-1642 - 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 0 BOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FROM DATE ISSUBP (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 ir`fd`1$62 and the Rules and-Regulations of San Joaquin CoL17�u,,n-ty�Public �Health Services. Jab Address '3/ �, L) D&z> City r c Lot^Size/Acreage Owner's Name _ e'Y1 s Address r Phone �,.. r.' � sr�s T i ddress �o�a�� G I d` cense No r Contracto i TYPE OF WELL/PUMP. NEW WELL 11 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 t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of INelI Excavation Dia. of Wel! Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public 1-7 Other H Delta Depth of Grout Seal Type of Grout I I Irrigation r`Approx, Depth I I Eastern Surface Sea! Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Wel! Destruction ❑ Well Diametef Sealing Material & Depth Depth Filler Material &Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR IADDITIONf DESTRUCTION I-I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: �� Water table depth SEPTIC TANK. ❑ Type/Mfg a Capacity_- No. Compartments PKG, TREATMENT PLT, ll o :. r ¢ Method of Disposal Distance to nearest: Well Foundati6n Property Line r ` x LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED. C1 Distance to nearest: Well Foundation _ Property Line ' r _ _ .,,�.�... _� _, ......__ r� n i ' SEEPAGE PITS I Depth s ! Sire Number SUMPS Ll ,?ii§ance to nearest j Well ! Foundation Property'Line DISPOSAL PONDS ❑ w I hereby certify that I have prepared this application and that jhe work.wilkbe-done in accordance with'San Joaquin county ordinances, state laws, and rules and reguiations-of-the San Joaquin"County' ; a { I 1 - } _r_ Home owner or licensed agent's signature certifiesthefollowing: 'SI certify,that in the performance of the work for which this permit is issued, !shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the fotlowing: "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 Caiifornle."I The applicant must call for all re r spectio s. Complete drawing on reverse side. Sign _' ' Title: . Date: n FOR DEPAR MENT USIE ONLY Application Accepted by Data Area Pit or Grout Inspection by Date \��Final Inspection by *s� Date Z Ly �jp moi/ Q +` Additional Comments: r' s y- � ,�S &,,v �// 7 J) r E3 �'a 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 CKRECEIVEDBY DATE PERMIT NO. INF CASH C r EN 13-24IAEV.1/85l ® r V > �Q`e�-�' 10 ""Iby EH;4.20