91-1556 - 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 f P O BOX 2009, STOCKTON, CA 95201 I PERMIT EXPIRES 1 YEAR FROM DATEJLED I '� (Complete in Triplicate) Application is hereby'made.to-Sen Joaquin County for a permit to construct and/or install the work herein described. This a application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San i Joaquin County Public Health Services. � Job Address _ , u44E' & -- - _ City Got Size/Acreage I+'I !F!? gic, T r7 r Owner's Name Address S — Phone 3'J 1 Contractor Address � Ct_ VI License No. Phone l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION put of Service Well ❑ PUMP INSTALLATION C] SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t [I Domestic/Private � _ ❑ Gravel:Pack ❑ Tracy _ _. Type of Casing Specifications ' V" Public (-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 0 Type of Pump H.P. State Work.Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION INo septic system permitted it 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: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation Property Line i� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth, Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ {1 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 persona subject to workman's compensa- tion laws of California." The applicant muKc-311 for all requirpl inspections. Complete drawing on reverse side. j y[ Signed Title: _4YU2feA Date: FOILDEPARTIMENT U.SE ONLY aoApplication Accepted by Date j, Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: i I Applicant — Return all copies to: Ban Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT N0. . EH 13.241REV.1/851 (--1 tA w '114 co I LiLt L I MQ -u-,i I q]-1!5g EH 14-26 i