90-1094 - Laserfiche WebLink

Home Browse Search

i t APPLICATION FOR PERMIT SAN J'OAQUIN 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 15SUED (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. Joh Address City Lot Size/Acreage Owner's Name ContractorA:R ddress w r icense No/,� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT_5 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ f OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES `� DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL = OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F Domestic/Private ❑ Gravel Pack.—D-Tracy..---------T-ype-,of_Casing Specifications q I'I Public C1 Other 171 Delta Depth of Grout Seal Type of Grout V I I IrriE7ation _,Approx. Depth I I Eastern Surface Sea[ Installed by `Repair Work Done tJ Type of Pump H.P. ' State Work Done Well Destruction O Well Diameter -Sealii4_materisl & D th ' Filler'Material Depth Depth ' TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIRlADDITION DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.1 Installation will serve:i Residence Commercial T Other Number of living units: _-L Number of bedroomsil Character of soil to a depth of 31 feet:I-tl-T'' r — _- - __ Water table depth SEPTIC TANK. ❑ TypelMfg� Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of Isposal Distance to nearest: t Well "_ Foundation Property Line LEACHING LINE ❑• No: & Length of Mines �- To al length/size FILTER BED ❑ Distance to neirest:', Well Foundation Property Line SEEPAGE PITS 11 Depth AMSite dumber '6MPS C1 Distance to nearest: Well -----T dation Property Line DISPOSAL PONDS ❑ � _ I hereby certify that I have prepared this application and that the work will be done in accordance with7 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 Wiasued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant t c or aU req nspections. C97plete drawing on se side. r� Signed X Title: Date: i F SE ONLY. Application Accepted by Data o Area Pit or Grout i Inspection by Date Final Inspection Dat_ Additional Comments: Applicant - Return s.11 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 CK CASH RECEIVED BY DATE PERM17 NO, INFO EH 13"21IREV"iin51 &/- r loho EH 14,26 v-�