90-813 - 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 O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE IS5UED (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 coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address __12001 N Thornton Road City. I,ndi Lot Size/Acreage ± Owner's Name City of I adi Address Phone333-6706 Contractorr_ - Sudan In . Address P'0• k t1rNlica CA 990 License No. 470732 Phone(916168 17 TYPE OF WELL/PUMP: NEW WELL ❑ WE L REPLACEMENT DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ STEM REPAI ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE LL Z OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONST TION SPECIFICATIONS L] Industrial ❑ Open Bottom 0 Manteca Dia. of Excavation Dia. of Well Casing fa Domestic/Private ❑ Gravel Pack C7 Tracy Typ of Casi Specifications f`l Public 1-1 Other 11 Delta D th of Grou Seat Type of Grout I f Irrigation .—._,Approx. Depth I 1 Eastern urface Seal Ins Iled by Repair Work Done L7 Type of Pump H.P. State Work Dane_ Well Destruction ❑ Well Diameter Se ng Platerial & Depth Depth F ler Material S Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I—IDESTRUCTIOVI o septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms 0 Character of soil to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg Capacity. - No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED [A Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line - DISPOSAL PONDS ❑ 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 subcontracting 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 st call fat all requi d inspections. Complete drawing on rev se side. Signed X Title: .. Date: Z DEPARTMENT USE ONLY Application Accepted by Date-- _ Area Pit or Grout Inspection by Date Final Inspection by'��_> Date rQ 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 FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATf PERM17 NO. • EH 13INFO H 24{REY.t i n 5i �� EH — __J