90-2141 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT _0 ,.. � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t� ,I ENVIRONMENTAL HEALTH DIVISION RECh VL 1601 E.. HAZELTON AVE. , PHONE (209)468-5420 AU 0 6 1900 P 0 BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES (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 a Ci t Size/Acreage Owner's Nam Address — _ Phone J� � r ss t-iCicense No. Phone ` .TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATIOfk� SYSTEM REPAIR ❑h� 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 F1 Industrial C Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing mestic/Private C) Gravel Pack ❑ Tracy Type of Casing } Specifications ( _ I'1 Public FI Other F1 Delta Depth of Grout Seal Type of Grout 1 1 Irrigation _Approx. Dep h` I r { Ins d b Repair Work Done LJ Type of Pump H. ork o e 1 Well Destruction O Well Diameter d� Sealing Material & Depth Depth / Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet,) Installation will serve: Residence_"1 Commercial---Other ' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: # Water table depth u SEPTIC TANK. ❑ Type/Mfg`� Capacity No. Compartmenti, II PKG. TREATMENT PLT.❑ k� `v Method of Disposal Distance to nearest: Well �Fouridation� '"- f ropeny Line LEACHING LINE CI No. & Length of lines ! Total length/size FILTER HED n Distance to nearest: Well Foundation� ' Property Line ; SEEPAGE PITS 11 Depth Size T Number E.» SUMPS Cl Distance to nearest; Well Foundation Property Line s ` T 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 L _---..,,.%...-....._ ---^... ____J Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for whicN this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation taws 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, I shall employ persons subject to workman's compensa- tion laws of California." The apphcan ust c V110 all required inspections. Complete drawing on re rerse side. 1 SignCd Title: Date: _ F RD ARTIVIFNT USE ONLY I Application Accepted by Date r. Area I V Pit or Grout inspection by Date Final inspection Date i Additional Comments: Applicant — Return all copies to: (San Joaquin County Public Health ? (Services, Environmental Health Permit/Services 11`1601 2. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOV T DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. INFO CASH + EH13.24{REV.I/a sl EH 3.26 4