91-1258 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT N 2' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES .1 ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 I, P 0 BOX 2009, STOCKTON, CA 95201 t. SIX B.XPIRES1 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San I Joaquin County Public Health Services. Job Address , i Cit Lot Size/Acreage Owner's Name Address /U 73 ;� �SO!t., q: Phone i Contractor ,L Address License No. Phone TYPE OF WELL/PUMP: NEW WELL [D WELL REPLACEMENT ❑ DESTRUCTION ❑.Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTE 'EPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPT TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUN AGRICULTU WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR AS CONSTRUCTION SPECIFICATIONS C] Industrial ❑ Open Bottom ❑ Mante ia. of Well Excavation Dia. of Well Casing �1 [:1 Domestic/Private ❑ Gravel Pack ❑ T y Type Ing Specifications C1 Public 1:1 Other L Delta Depth of Grout a Type of Grout I 1 Irrigation � Approx. D 1 I Eastern Surface Seal Installed by R� Repair Work Done 0 Type of P p H.P. State Work Done Weil Destruction O Wel rameter Sealing Material 6 Depth pth I Filler Materiel & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION No septic system permitted if public sewer is 1 available within 200 feet. Installation will serve: Residence=i Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ '1 Method of Disposal Distance to nearest: Well Foundation Property Line � I LEACHING LINE 0 No. & Length of lines Total length/size ) FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth r Size Number SUMPS Ll Distance to nearest: Weil Foundation�. _ _ Property Line DISPOSAL PONDS ❑ I hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county o(dinances, state laws, and rules and regulations of the San Joaquin lCounty q 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." l The applicant must call for all required inspections. Complete drawing on reverse side, Signed X Title: Date: FO EPA=ENTE ONLY Application Accepted bysAA Date _ Area Pit or Grout Inspection by Date Final Inspection by ---) Data Additional Comments- i 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-26 AMOUNT DUE AMOAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH A-211REV.1/115) Cfl WJ