91-1274 - Laserfiche WebLink

Home Browse Search

j APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION i 1601 E. HAZELTON AVE. , PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. r Job Address 15-e& Cit Lot Size/Acreage Owner's Nam _ Address Phone Contract {r Address e. License bio 5 Z Z6 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O 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 f 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications /n I'1 Public t-1 Other ri Delta Depth of Grout Seal Type of Grout ' I 1 Irrigation ._....Approx. Depth I 1 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 3 Depth TYPE OF SEPTIC WORK: NEW INSTALLATIOWZ REPAIRlADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is r a v r A__� _- available.within.200 feet.) Installation will serve: Re erlce— Commercial Other " Number of living units: Number of r om Character of s3,/oil to a depth of 3 feet: r Water table depth ��FF SEPTIC TANK. Type/Mfg Capacity _ No. Compartments E ; PKG. TREATMENT.PLT. ❑ r Method of Diipxsal ,4 Distance to nearest: Well _ Foundation _ Property Line r !" 'LEACHING LINE y� No. & Length of lines Tal length/size FILTER BED ❑ a Distane'e.to nearest, Well Foundation Property Line_ t SEEPAGE PITSDepth v Size _ Number -- SUMPS { LI Distance to nearest: Well Zead Foundation ed Property Line ". 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 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." A The applicant m call for a r uir inspections. Complete drawing on raver de Q Signed Title: Date: ` FOR DEPARTMENT USE ONLY f r� Application Accepted by Date : Area% - ON or Grout Inspection by Date_ Final Inspection by�Q Date 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 A 0S) FEAMO ;UNT DUE AMOUNT REMITTED CASH CK i RECEIVED BY DATE PERMIT'No.EH t3-244REV.tis 5EH M-26 L