FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION SAN�OAQUIN COUNTY PUBLIC HEALTH•VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/dr 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 Services. Job Address 11O S /.�CFr/I�CY �/� City 42 Lot Size/Acreage Z— � Owner's Name "yy'T99`nnodress Phone Contractor ddress416_�� tiicense No. S O Phone g 6741 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1.1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 9/_ SEWER LINES 51 l DISPOSAL FLD.4L+_ PROP. LINE ?tel FOUNDATION 6LV� AGRICULTURE WELL OTHER WELL A/c_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation !O Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ ✓L Specifications I'1 Public Cl Other fl Delta Depth of Grout Seal - Type of Grout I I Irrigation _Approx. Depth yYEas(ern Surface Saul Installed by 6W GJ�w�O'��i' Repair Work Done L3 Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth S TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is , available within 200 feet.) r 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 w PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line \ LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 applicantcal or-a squired ins ctions. Complete drawing on reverse side. Signed Title: ��,Um�• "r'�1V�1"c^ Date: ,11tj1�,-�.�,(n FOO DEPARTMENT USE ONLY Application Accepted by FOR '/ /� -- Date I I� 1 �3 Area Pit or Grout Inspection by Li e- Date h2 ( / Final Inspection by PY fC Dale Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services 3S t71 Environmental Health Permit/Services ) � 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO, S� NFO CASH oe g ,00 . EH lY]�IREV.r/x si EH 14}D