90-1283 - Laserfiche WebLink

Home Browse Search

t APPLICATION FOR PERMIT �+ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES rt` ENVIRONMENTAL HEALTH DIVISION 1601 E.' HAZELTON'AVE. , PHONE (209)468--3420 t P O BOX 2009, STOCKTON, CA 95201 DRRYTT XPIRES 1 YEAR FROM DATE ISSUBP 1 (Complete i1a Triplicate) -- _4 Application is hereby made,to San Joaquin County for a pervA to construct and/or install the,vork herein.described. This �- * application is made in compliance with San Joaquin Count Ordinance No. 549 and 1862 and the Rules and Regulations of San ,� Joaquin County,Public Health Services. k Job Address , / /�a 1 � City Lot Size/Acreage Z r ` Owner's Name F Address Phone-2 r?` �6"� S Contractor G 7 Address ' V License No_3 77 3TY _Phone 3 " TYPE-OF WELL/PUMP: NEW WELL 4 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION • SYSTEM REPAIR C7 OTHER ❑ Monitoring Well C7 01 DISTANBa--- CE TO NEAREST: SEPTIC TANK .r SEWER LINES / DISPOSAL FLO. -'--PROP. LINE S fl y r FOUNDATION - - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE O "PROBLEM AREA CONSTRUCTION SPECIFICATIONS � - Cl industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia..of,Well Casing 4--&e Domestic/Private %�1 Gravel Pack 0 Tracy Type of Casing— Specifications I'i Public I.l.Other' Cl Delta Depth of Grout Seat 5 Type of Grout I I Irrigation � �Approx.-Depth I I.Eastern Surface Seal Installed by r 7r7>✓� Ritpair Work Done U Type of Pump H.P. State Work Done Ilk Sealing Material i Depth ~` a i, Well Destruction ❑ Well Diameter .---�------- Depth Filler Material & Depth l " TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDI'T'ION I I DESTRUCTION I I AN6 septic system permitted if public-sewer is available within'2001eet;M installation wilt 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 Capacity No. Compartments PKG. TREATMENT PLT. C1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE , 0 No. & Length of lines Total length/size FILTER BED -Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Dep h Sire Number SUMPS Ll 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 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, 1 shalt 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 require inspections. Complete drawing on reverse side. e— Signed`X�- ✓�� Title: a Date: FOR DEPARTMENT USE ONLY i r Applicatio Accepted by Date�/ , Area Pit or o t Inspection by 4' Date ' Final Inspect n by �j o � Dated` / Additional Comments- ref T' y Applicant - Return all copies to:' San Joaquin County Public Health W G� Services, Environmental Health Permit/Services �� Z 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AM(OUNTf�REMITTED CASH RECEIVED BY DATE (� PERMIT'NO. a EH 13-24 IFI IDJi ! tl� V a �(,y� � �/ �(�4 , EH ZI-3a v v F ky 4