SU0002230 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 P O BOX 2009, STOC&TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 1s 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 ZZ—/ City Lot Size/Acreage Owner's Name ("� �- ddress Phone Contractor Address `�7�Y r� "' License No. � phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications II Public 1_1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth O TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence 1k Commercial _ cher Number of living units: Number of bed o Character of soil to a depth of 3.feet: 67 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal C Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size ^� FILTER BED ❑ Distance to nearest: Welles Foundation Property Line a_-- SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation `� Property Line ! DISPOSAL PONDS r C? L�2Cz 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 this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." Theapplicant mu all for II requ ed inspections. Complete drawing on reverse side. Signed X J' Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 1Y 15 Area Pit or Grout Inspection by Date Final Inspection VIA Date� Additional Comments: Applicant – Return all copies to: San Joaquin County Public Health Services, Envirorq*ntal Health Permit/Services 1601 E. HazeltonAve., P 0 Box 2009, Stockton, CA 95201 IEEE AMOUNT DUE AMOUNT REMITTED CK f CASH;f RECEIVED BY DATE PERMIT'NO. . EM 13-24(REV.iin5 �! `L91/ LN I /[ (�j�©U Z—Y7-3 S�J� f 7f f/3� EH.2e 6 V