90-729 - Laserfiche WebLink

Home Browse Search

FOR PERMIT APPLICATION F P IT 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 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 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 o0 kmsba/cc/ aZ,&f t: S-ETvoQ; City v Lot Size/Acreage Gf iC/D. j Owner's Name //gle 4-4FLac/:% Address 1�`+-+� Phone Contractor 4rbrti�C?Qt sE+2Gw: Address POO.&Ax W License No. IWO Phone 2•�®7 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [:l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (1 Public Cl Other (1 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 Destfuction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF-SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION V DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_-:1kCommercial_ Other Number of living units: Number of bedrooms 2 _ 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 Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size1�r�S _ Number SUMPS *v Distance to nearest: Well Foundation Z9 ` Property Line XSf DISPOSAL PONDS ❑ I 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 (lam 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 applican must call for all required inspections. Complete drawing on reverse side. Signed Title: E-4A Date: Z 9 OR DEPARTMENT USE ONLY Application Accepted by OL._ � o Date Area a5___ I Pit or Grout Inspection by _ Date Final Inspection by �!�![�:Date Additional Comments: r LcJ Applicant - Return all copies to: San oaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO 60 1OUNT DUE AMOUNT REMITTED CASN RECEIVED BY DATE PERM-II NO. . EH 13.2 (REV.gins) �10: ©� 7U __� / �� /� /�0U 9(J�/� EH 462E