FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION SAIF JOAQUIN COUNTY PUBLIC HEALTii S$RVICES e �.��LQ ENVIRONMENTAL HEALTH DIVISION ee- 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 952+01 PERMIT E%PIRE3'1 YEAR FROM DATR .ISSUED (Complete in Triplicate) Application is hereby :lade to San Joaquin County fora permit to construct and/or install the work herein described. This application is :rade in costpliance with San Joaquin County Ordinance leo. 549 and 1862 and the Rules and Aegulati of San Joaquin Countyp Public Health Servicer. JobAddress �+ ��''�,]�"`""t^ �rtU�-- City �tacJZ o Lot Site/Acreage 0 C-erei owner's Name A(l-CO ergA, - -'t') 120-ga Address V01kx S'_ft_It Aar. _ea ggqo --Phone (41'V6-71-Z44.g '' ++ 6 3'7b s�lS Contracttxwa r �'v"` Address Pte. (jbx7L(oF(-r'..co�-. laaense No. CjrT 04C Phone�g� - 3 TYPE Of WELL/PUMP: NEW WELL WELL REPLACEMENT 17.1 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM RE AIR 0 OTH R Monitoring Wells ��AA �1t1S -SOrSet+ a+r 4rwa.edvillr DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES jb""�""""N"� I POSAL FLO. PRO . LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I10 Aek - V" Dia. of Waft Casing F) Domestic/Privet* ❑ Gravel Pack ❑ Tracy type of Casing_ QV4- R Ificstlons PdC. 1'1 Public 1-1 Other Delta$(odt4o., Depth of Grout Seal y"I 'C. rr4wf�[ik� yp pf Grout - �( i I Irrigaiipn 3Q Approx. Depth 1 I Eastern Surface Seal Installed by t.Jer_1*30L 13V all E�\�►. at 4rY� ='Repaoir w�orwk v'As U Typa of Pump 1Jo^�� H.P. - State Work one Well Destruction ❑ Well Diameter Sealing Material i Depth Depth. Filler Material i Depth 4-71 lit Spar S _ TYPE SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system itted if public sewer is _ avaNabN withi feat.) Installation rw: Residence_ Commercial_ Other j Number of living urn Number of bedrooms Character of Sone to a dap f 3 feet: Water table depth SEPTIC TANK ❑ T fg Capacity No. tompartminb PKG. TREATMENT PLT.❑ • - Method of D*iolal. Distance to near Well dation Property Line LEACHING LINE L, No. d Length of lines Total length/size FILTER BED 171 Distance to neerast: e11Foundation Property Line SEEPAGE PITS 11 Dept Sire Number 5 - SUMPS Isanu to rreanst: Well Foundation Property Lihe DISPOSAL PON ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with Son-Uotiltiuln courtly ordinances, state laws, end rules and regulations of the Sin Joaquin County Home owner of licensed agent's signature certifies the following: "1 certify that In the performance of the work for which this permit Is issued, 1 shall not employ any person M 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 j'_u_-st-can for all requited In tions. Complete drawlMonerse side.Signed Xr'r,�d!=.�dais-4' FOR DEPARTMENT USE ONLY pp Application Accepted by I►�l.(r� - D1% 9` ``47 5 Area Ph 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 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'NO. 1; INFO a Q )Q� EH 13.24 IN I/Asl � O D (� 1• al- 1�� 1(T✓� EH 14.36