91-1388 - Laserfiche WebLink

Home Browse Search

ADPLICAT.,ON FOR PERMIT SAN JOAQUIN COUNTY PUBEIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 Pr kRYIT 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. A Job Address City Lot Size/Acreage Owne('s Namy Address �,1�o`r1 �. __ __ ______ Phone Contractor AddressPhone 6 TYPE Oli WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C"3 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR � OTHER ❑ Monitoring Well C7 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 D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing KDomestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications r, Public 1-3 Other 1-1 Delta Depth of Grout Seal Type of rout I I trfigation Approx. Depth I Eastern S rface Seal Installed by `} Repair Work Done X Type of Pump H.P. State Work Done a Well Destruction D Well Diameter Sealing Material & Depth Depth Filler Material b Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I i DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet,) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _ - __ r Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Co Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED -F1 Distance to neaiaest: Well Foundation Property Line � t SEEPAGE PITS 11 Depth Size Number SUMPS L:1 Distance to nearest: Well Foundation _ Property Line DISPOSAL PONDS 0 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 fotlowing: "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: 1 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject;tov(t76rkm,85mp sa- tion laws of California." The appli must all for all require ".ctio . Complete drawing onrev r ide.Signed Title: — �_" f S Date: t EQ&DEPARTMENT USE ONLY Application Accepted by Date Area �— Pit or Grout Inspection by Date Final Inspection by Data 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 ff�NEF"EO AMOUNT /DU(EE AMOUNT REMITTED CK A CASH RECEIVED BY DATE PERMIT'NO. + EH1 3.24IAEV.i/H5i jJ� + �;./,-/ (t? �o•C 1 �. (�1-�3 EH i4-le 1 i