FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APION FOR PERMIT SAN d*UNTY PUBLIC HEALTH SERVICES 1.1 S�ENTAL HEALTH DIVISION CA�� 'OC}9, STOCKTON, CA 95201 �Q Ot1�A U' , (2 09) 4.68-3 L/6 F=3 y 21� gP+�ZO G�C�iiEWIT EXPIRES 1 YEAR FROM DATE ISSUED SVS` (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the v rka Abed. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Eu one of San Joaquin County Public Health Services. 13.c- v- Ser✓r'CL Sr r,'c,, C yf ` Job Address 'aQ Sovrh Clrtry K-ct Lc..c City L OCt i C Gts age Jig,a00 fT'2 Owner's Name U rre.~o r Address S L S W.e.s r rA,r ,., If614 ,CLQ Phone .2 a g- s d z -Ol fyl Contractor 1stLe_S} Address� � /' C✓Gr�C�. License No. 57-5 1 7CI Phone�$'7z76 TYPE OF WELL/PUMP: NEW WELL C;d' ( WELL REPLACEMENT O DESTRUCTION O Out of Service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK N9 SEWER LINES * 20'1}s" DISPOSAL FLO. VA PROP. LINE LSZ i✓u 111W-25/VW-L C FOUNDATION .8'120' AGRICULTURE WELL OTHER WELL ar y � PITS/SUMPS A/4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial O Open Bottom O Manteca Die. of Well Excavation ,, 8�� Dia. of Well Casing Z y O U Domestic/Private 0 Gravel Pack O Tracy Type of Casing P✓L Specifications M Public I4Other p Delta Depth of Grout Seal 3411 .6,1 Type of Grout Nlut M Irr,Oation ;rS/ZJ;C'Xpprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction O Well Diameter L Sealing Material i Depth /✓c,,7- Ct+. ..r, v Yd'/30' �f 17" Depth ?SV(-O' Filler Material L Depth Mv. ;- r�� 7r?m TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION Cl INo septic system permitted if public sewer is /1 available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms CID> Character of soil to a depth of 3 feet: Water table depth V SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 hereby certify that 1 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 Sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall empioy 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�Gu� YTMGQIir.� � EV+)C r4e.'.. 11.. Title: 6-tvly ,dig )1(r Lf 3S Date: F DEPA USE ONLY �} Application Accepted by Data -3 ^ ! Area -) 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 DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STUCKTON, CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CK ' RECEIVED Y INFO /' � CASH ERMIT NO. DATE P