90-1859 - 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 P O BOR 2009, STOCKTON, CA 95201 i PE MIT EXPIRES 1 YEAR FROM DATEIS5U I (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 S(e�r�viices. p 'J 8� Job Address o r t"41� t n City Lot Size/Acreage , c2l�Owner's Name �r 1�s. L n 1. sddress d/ ) . p �' Phone 31 t �^ � -3-5615 Contractor } G ddress d'� =- - License-No.�J3LZ-� _ Phone YPE OF WELL/PUMP: NE WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ . OTHER © Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIOkl AGRICULTURE WELL OTHERIWELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS R Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing pQ Domestic/Private Gravel PackI ❑ Tracy Type of Casing ' Specifications filacv I l�Ll" y i'1 Public 1-1 Other R Delta Depth of Grout Seal" �n �r Type of Grout I I Irrigation ��..Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump 5�1�' H.P. ' - / State Work Done Weil Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material dDepth f TYPE OF SEPTIC WORK; NEW INSTALLATION f I REPAI /ADDITION It.t-0 TRUCTION #•111•No-seplic system permitted if public sewer is available within 200 feet.1 # Installation will serve: Residence " Commercial— 0th r Number of living units: Number of bedrooms Character of snit to a depth of 3 feet: "Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ } ! F Method of Disposal Distance to nearest: Well F ndation Property Line -� LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ,Nell Found tion Property Line /' SEEPAGE PITS 11 Depth / —Size Number - SUMPS Ll Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with'LS an Joaquin county ordinandes;-si to laws, and rules and fegulations of the San Joaquin County I Home owner or licensed agent's signatureArtifies the following: "I certify that in the performance of the work for which this permit is issued;l shall no employ any person in such manner as to beclome subject to workmen's compensation laws of California."Contractor's hiring or sub-contracting.signature certifies the following: "I certify that in the.perlormance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- tion laws of California." The applicantmustcall for all required inspections. Complete drawing on reverse side. �5igned X [ h l.e�t 1 Title: . j'1U1h� Date: E?EPARTMENT USE ONLY Application Accepted by Date VArea.= Pit o rou Inspection by -- Date a r Final.Inspection IN Daw, z� 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 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMI7'NO. + EH13241REV.1/n5i � tO� \010 �t_I(7/4/p � EM 64.2e