90-1572 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ( kN *AQUIN NTY (PUBLIC ALTH �ERVICES �J ENVIR TAL HEALT DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PXMIT EXPIRES 1-!EAR FR >H DATE ISSUED �� N (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 Public Health Services.Job Address r 02— SU i .,r 4) City C1�i�AO&I _ Lot Size/Acreage r hVS � 9c h:_ Owner's Name —,o/ rc., Address z �/S O h �Z–P 2 7 Phone Contractor W e Address t 2 - ll*l h _ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well El PUMP INSTALLkTIO Cgs SYSTEM REPAIR 0 OTH R ❑ Monitoring well C3 DISTANCE TO NEAREST: SEPTIC TANK 20 SEWER LINES *1 DISPOSAL FLD. 06-51 PROP. LINE FOUNDATION Z^t3`` AGRICULTURE WELL OTHER WELL--; PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing kt'tOmestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public EI Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. l it; State Work Done _ Well Destruction ❑ Well Diam r _ Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION i I INo septic system permitted it public sewer is ' j 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 Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE LI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 } Depth Size Number SUMPS f_I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl `. ' 1 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-contracting signature certifies the following: "I certify that in the performance of the work for which thii permit is issued, I shall employ persons subject to workman' tion laws of California." , s compensa- The applicant mus all fpr ii required inspections. Complete drawing on reverse side. Signed X_t Title: r Date: 22 FOR DEP FITMENTUSE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant – Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services FEE 1601 E. Hazelton Ave., P 2009, Stockton, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'N0. ASN + EH 13-24(REV.i �. r,/_�� EH 76M �u U l%