90-793 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT USAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 11 ENVIRONMENTAL HEALTH DIVISION ! IA601 E. HAZELTON AVE. , PHONE (209)468-3420 E P O BOX 2009, STOCKTON, CA 95201 REMIT ESPIRES 1 YEAR FROM DATEI5$U$D (Complete in Triplicate) ' Application is hereby made.to wan Joaquin County for a permit to construct and/or install the work herein described. This application is liege in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r City D Lot Size/Acreage Job Address ` Owner's Name K� ^— - Address Phone Contrattor !-�F —Addresses License No.®Z� � Phone � - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ 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 L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing P Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications ['1 Public (-I Other fl Delta Depth of Grout Seal Type of Grout I 1 Irrigation T Approx. Depth I I Eastern Surface Seal Installed by Y, Repair Work Done _❑ Type of Pump H.P. A State Work Done Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REP-AIRtADDITION- BEST-RUCTION-t-l--ffVo septic system permitted if public sewer is �� 1 available within 200 feet.) Installation will serve: Residence_�• Commercial— Other s U !Number of living units: —/_ Number of bedrooms Character of soil to a depth of 3 feet: t� 1 �- Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity--- No. Compartments f PKG. TREATMENT PLT. ❑ � ; ,-. Y" s Method of Disposal Distance to nearest: Well i. O ,.Foundation Property Line .* - s LEACHING LINE k No. & Length-of lines — %-YDD/ � - Total length/size - �� :; j FILTER BED [I Distance to nearest: Well �'�� Foundation! �'T Property Line SEEPAGE PITS "l I Depth 3 Size Number - SUMPS GI 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 irnaccordance 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 certifyat thin 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 r 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- lion laws of California." The applicant must call for#W re ui ed inspections. Complete drawing on reverse side. l Signed Tule: - - Date: FOR DEPARTMENT USE ONLY Application Accepted by _ Date G� r Area �� 9-5 Pit or Grout Inspection by Date Final Inspection by v Date Additional Comments: i h Applicant - Return all copies to, San Joaquin County Public Healtp r f Services, Environmental Health Permit./Services-__ 'P"0 Boz 2009, Stockton, CA 95201 TM .. FEE AMOUNT I1t& AMOUNT REMITTED- ^CASH RECEIVED BY GATE PERMIT'NO. INFO r1 /� EN 1324(REV.%/n SS �� ` ✓ j��;VI� G ` �„ ,� 1/ ��.r `�L� d - EH;4.29