76-419 - 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 BOX 2009, STOCKTON, CA 95201 PERMIX 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 coapliance with Sat: Joaquin County Ordinance No. 549 and 2862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City Lot Size/Acreage Owner's Name Address Phone iAddress License No. Phone Contractor _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing 17 Domestic/Private ❑ Gravel Pack L] Tracy Type of Casing Specifications I'1 Public I:1 Other t 1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L3 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 f I REPAIRIADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is ii available`within 200 feet.I ` Installation will serve: Residence i Commercial___Y-_ Other s , • 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. CJ Method of Disposal Distance to nearest: Well a Foundation Property Line i f LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS', 11 Depth Size Number SUMPS C3 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 subcontracting 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." The applicant must call for all required inspections. Complete drawing on reverse side. r i Signed XTitle: Date: t FOR DEPARTMENT USE ONLY I I Application Accepted by _ Date Area Pit Ir Grout Inspection by Date Final Inspection by Date t 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITN0. . EH 13.21IREV.,/K51 £H A-2e