90-1079 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-35420 P O BOX 2009, STOCKTON, CA 95201. I SIT EXPIRES 1 YEAR FROM DAIE 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 trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. y� eft /�j Job Address es I1 l T ► ' gLJJ--C�"_. _� . _ City�/ !!,alljeefg-- Lot size/Acreage Owner's Name Address _ (30/7 6012 G!g• i Phone Conlracto( ��rf f%'r Address AQX Iu__r5 _ ^License No. Phone _1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION 0 Out of Service Well . ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C7 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 D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'} Public I:7 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx.,Depth I I Eastern Surface Seal Installed by Repair Work Done U Typo of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth ± TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION [ I DESTRUCTION I I INo septic system permitted if public sewer is f' available},within 200 feet.) Installation will serve: Residehcer Commercial,____. Other Number of living units: i Number of bedrooms Character of soil to a depth of 3 feet: c Water table depth SEPTIC TANK 111"Type/Mfg 64L Capacity No. Compartments PKG. TREATMENT PET. ❑ Method of Disposal v Distance to nearest: Well Foundation Property Line �1 D LEACHING LINE Vr'�`No. & Length of lines d Total length/si�ze'' FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth —Size Number t SUMPS LI Distance to nearest: Well Foundation 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 must call for all r Mired inspections. Complete drawing on reverse side. •Signed Title: ._ Date: [Q J. • .�, DEPAR ENT USE ONLY ti tw Applicatiori Accepted by,* V/ Date �� res I Pit or Grout Inspection by f r)w Date Final Inspection by Date '� p Additional Comments: Applicant - Return all copieawto: tion Joaquin County Public Health � Services, Environmental Health Permit/Services 1641 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE` ? INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. _ f EH 3-24 + Eli 71 Zd(REV.i)N 51 /O _ _ — �. [! 1 0