FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION i I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, ' PHQNE (209)468-3420 II P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISS ED (Complete in Triplicate) Application ishereby d.,W 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. $49 and 1862 end the'Rules and Regulations of San Joaquin County Public/Health Services. Job Address Cd6.J W � �,/ I [5 Cit( L _Lot Size/Acreage CLQ A Owner's Name " ' fcf '�A� Addreu,)ft W Cwr/LCfT'r'�7r,fc ,4 f Phone Con Ifactor &LZs Z wLE/Er4ddressm 41"'�%JG/O �/ License No2]`7y-1- .Phone A93 E.3f TYPE OF WELL/PUMP:, - NEW WELL ❑ WELL REPLACEMENT n. DESTRUCTION,.❑ Out of Service Well ❑ PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well LT DISTANCE TO NEAREST: SEPTIC TANK ` SEWER LINES DISPOSAL FLO.._ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL_ yPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA .-.CONSTRUCTION SPECIFICATIONS - - {p��Industrial ❑ Open Bottom . ,❑ Manteca /Dia. of Well Excavation ' .T Dia. of Well Casing 1 El Wmetaic/Private ❑ Gravel Pack7 ❑ Tracy .Type of Casing_ Specifications , 1'I Public I:1 Othy P Delta Depth of,Grout Seal -Type.of,Grout — I I Irrigation 25PAppmx. Depth I I Eastern i' $urate Seal Installed by ' Repair Work Done A,r Type of Pump iI457� H.P. a /^L_ �/Jr - Slate Work:Done .'Well Destruction ❑ Well Diameter Sealing Material& Depth . Depth :Piller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I I INo septic system permitted it public sewers } available within 200 teat.) Installation will serve: Residence— Commercial—_Olher- Number of living units: Number of bedrooms Character of Will 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 Lips LEACHING LINE ❑ No. 6 Length of lines Total IenplMsiz '++AAVVMM' ��.•��''�� _ 1-FILTER BED ❑ Distance to Well , Foundation PrppeitY111YL�„�ppQ SEEPAGE PITS 11 Depth '—Size Number SAN�l �I,FOAQIUI C(TUJNTY SUMPS Cl Distance to nearest: well Foundation - DISPOSAL PONDS - ❑ ;* IviLlON _ I hereby certify that 1 have prepared this application and that the work will ba_dune 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 became subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the follouiing:'9 certify that in the performance of the work for which this permit is issued,I shall employ portion&subject to workman's compensa- tion laws of California.- .The applicant must call I all required inspections. Complete drawing on reverse side. 1 Signed Title: Data: FOR DEPARTMENT USE 4LY p Application Accepted by Date 3 Area Ph or Groat[Ina - psaion Wu Date Final Inspection M Date Additional Co011Mnta: Applicant - Return all copies to: San Joaquin County Publie.Health Services ir Environmental Health Permit/Servlcee l?i 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 r INFO M AMOUNT DUE AOU[NTT REMITTED CQA�SN flECEI'ED By " DATE PERMIT NO . Eh oras laEV.r„s) R 7 .J 6Da� ,' EN 16x1