90-3172 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT f ; SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION l 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FRAM DATE ISSUED i (Complete in Triplicate) l 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 Co ty Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City Zeit Lot Size/Acreage P Owner's Name Art r Address<4__ _-�— Contractor �Addressx.�_?&--zxLscense No. ✓ Phone TYPE OF WELL/Pump: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. (FOUNDATION"":1__—AGRIC0TL•1RE_WELL---=-- O "'"-PITS/SUMPS INTENDED USE ` TYPE OF WELL PROBLEM AREA CONST N SPECIFICATIONS n Industrial D Open Bottom ❑ Manteca la. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack D T Type of Casing Specifications �I'I Public [-1 Other Delta Depth of Grout Seal Type of Grout I I lrri0ation Ap epth I # Eastern Surface Seal Installed by f Re air Work Done L� I ,� p � ype of Pump N.P. Stats Work Dane_ Well Destruction O �4ell Diameter Sealing Material°& Depth F k Depth - ^Filler Material % Depth 04 tt TYPE'NOF SEPTIC WORK: NEW INSTALLATION t I REPAIRIADDITIO DESTRUCTION I I INo septic system permitted if public sewer is Ol / J\ I 1 1 .` available within 200 feet.l / Installation will serve: Residence-X, Commercial_ Other 1 Number of,living units: /. Number of bedrooms b . Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK d Type/Mfg 'Capacity. �µi No� Compartments PKG. TREATMENT PLT, 01 ' � �'� r Method of Disposal Distance to nearest: Well Foundation r�prooerty Line LEACHING LINE No.'& Length�of lines T:ota`E lengih/size r U ��• _ f FILTER BED Cl Distance to nearest:- Well—'Foundation Property Line € � SEEPAGE PITS I I DD th Sire k ! Number" h SUMPS L pistance to nearest: Well 1AP12 _ Foundationproperty Line . /Li DISPOSAL PONDS L7 Y 1 / 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 t ',,7 i € Home owner or licensed agent's signature cenifies 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." y r X The applicant m call for-all required ' ns. Cogtplete drawing on Signed - Title: Date: R DEPARTMENT USE ONLY Application Accepted by _ _Qr 6�rl, Date _-�d� , .�.Lj Area �� Pit or Grout Inspection by -- Date final Inspection Additional Comments: a& 12- Applicant - Return all copies to: San Joaquin County Public:,Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P D Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED 8Y DATE PERMIT'NO, EM 1 .24 1REV.,/n 51 j EH 14.28