SU0010733 SSNL - 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 4 P O BOR 2009, STOCKTON, CA 95201 C_ K, ' I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED o0 (Complete in Triplicate) Application lehereby made11,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. {. /' ,�}y�� y /� Job Address `�lT I M C- e City l F 1 Ltft Size/Acreage C7 / (_ti('A, Owner's Name'- ^- r Wddrass C p�,r_�1 Phone f5 - a C i Contractors ` r Address License No. Phone ' TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMPj,INSTALLATION [3 SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ 0 FOL14DATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ((-- ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing rF^ N Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications G ii I'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout- I I I Irrigation _Apptox. Depth I I Eastern Surface Seal Installed by 11Y/ Repair Work Done [] Type of Pump H.P. State Work Done_ ' Well Destruction ❑ Well Diameter Sealing Material i Depth Depth 11 Filler Material i Depth TYPE OF SEPTIC WORK; NEWINSTALLATfOtUl REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is I available within 200 feet) Installation will some: Residence_ Commercial_ Other Number of living units: _ II Number of bedrooms..A_ Character of coil to a depth of 3 feet: Water table depth r1 SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ �Iy Method of Disposal Distance to nearest: Well� Foundation Property Line i1 ' LEACHING LINE ❑ No.fli Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ii ' SEEPAGE PITS 11 Depth Size _ Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 1 1 hereby certify that I have prepared this application end 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 workmen's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I comf thatthe perfo of th h rkkor which this permit is issued, I shall employ persons subject to workman's compensa- tion lows of Calilornla." � The applicant must c� or all spa a. C d mg on reverse side. .y Signed Isle: Date: F"PART!AAT USE ONLY ' Application Accepted b �1 Data Area Pit or Grout Inspection by I Date Final Inspection by Date Additional Comments: it i Applicant - Return all copies to: San Joaquin County Public Health ' Services, Ebvironmental Health Permit/Services 11 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT NO. INFO CASH 114.25 .lixsl la� �� o I 1 of-ls I� `7► -C) 7 N