FIELD DOCUMENTS - 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 0 BOXi2009, STOCKTON, CA 95201 - RERMIT EXPIRES 1 YEAR FROM DATE-_ ][ ED : (Complete-in Triplicate)' „t Application is hereby made to San Joaquin County for a permit to construct and/or install the,vork herein described.:, This application is made in compliance with San Joaquin"County Ordinance No. 549 and 1862 and the kules and Regulations of San Joaquin County Public Health Services. a: h1 j'' �/G10 a,' Of- Lot Size/Acres e Job Address _/ � ILAV '' --- Cit - B Owner's Name Address Phone Contractor ] ��19J Address --�O' ST GS4-UJ`�� License No. �3 r-9-)C Phone "a A.2 2, TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ s OTHER!J93' Monitoring Well C7 E!' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER.WELL FITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial 0 Open Bottom ❑ Manteca' Dia. of Well Excavation Oia, of Well-Casing I' �s CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('I Public Cl Other rl Delta Depth of Grout Seal Type of Grout4 .711-11-T I I Irrigation _Approx. Depth I 1 Eastern 5A Surface Seal Installed by ? Repair Work Done U Type of Pump H.P. State Work Done Wel! Destruction ❑ Well Diameter Sealing Material & Depth E� J'C41' L:i14) P/-"r16- V Depth Filler Material& Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION-1-1 INo septic system permitted if public sewer is available within 200 feet.) i 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines -Total length/size ,i FILTER BED ❑ Distance to nearest: ., Well. Foundation Property Line SEEPAGE PITS Depth Size Number E S 1I De p 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 I. I� 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X 'Title: Yet Date: FOR DEPARTMENT.USE ONLY ` Application Accepted by IUOL, Date E Area i;. Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services n ; 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 ' FEE AMOUNT DUE AMOUNT REMITTED GK s EI ED Y DATE PERMIT'NO. INFO 4 p�'� �{ �y� CA5H EN 13-24fREV.�iw51 ail t7 L.W • l.�tiJ I +� II �f LI� 1� !O- 31c f EH .4.20