FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION' SA�JO,AQUIN `COUNTY PUBLIC "HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N :SAN JOAQUIN, PHONE (209)468-3420 P. Oi'`BO% 2009, STOCKTON, CA 95201 ' PERMiTl' IRES I YEAR FROM DATE ISSIFED } �'{COmplete in" Triplicate) Application is hereby made to San Joaquin "Count for I' application is made in c y Permit to construct and/or inataLL the work herein described. This ompliance vith San4baquid County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County.Public Health Services. Job Address i3Oll, #: Z (0 {SI 2S� .rflE4 Ik ' �'z=�; � t/� AGn� City '"'LY Lot Size/Acreage F .s LAW D{-PC.ES A7 Owner's Name ,I Addiegig �$Jb L�NAL &1-0 McXW 191) r ss Phon Contractor D&-lEd'I WTEO Addres's .;0bZ4 oLJ�A&, bI Li License No. ;Phone TYPE OF WELL/PUMP; NEW WELL ❑+,�li:, ;j WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION .., SII,<. t, iF SYSTEM REPAIR 0 THER ❑ Monitoring Well $� DISTANCE TO NEAREST: SEPTIC TANK (#JOG T1 JUf btpp ']f SEWER LINES DISPOSAL FLD. PROP.LINE FOUNDATION I �'1' AGRICULTURE WELL OTHER WELL �t PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industria! ❑ O I+ IVA pen Bottom Manteca' Dia. of Well Excavation" Dia. of Well Casing n Domestic/Private ❑ Gravel Pack Xilaey. Type of Casing Door Xilacy I 9- t;✓ Specifications I.1 Public C1 Other 6W.4 NXr fl Deli,,,.a i! Depth of Grout Type of Grout I I Irrigation A ast U ppras. Depth I 1 astern Surfacs'Sau! Install by } Repair Work Done ❑ Type of Pump H;P. S tl�Wock one € Well Destruction ❑ Well Diameter , Sealing Material8 Depth 6�WNtI 43 P Depth J';iil Filler Material i Depth tV dtLLGQ .4J-�-D 1 I TYPE OF SEPTIC WORK: NEW INSTALLATION t I i3,REPAIR/ADDITION f I DESTRUCTION I I (No septic system permitted it public sewer is t + +1'ii 4 available within 200 feet.); Installation will serve: Residence— Commercial�`7� Other O Number of living units: Number of bedroome.'�:"s" fl f Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments !; PKG. TREATMENT PLT:❑ "' '€ Method of Disposal i Distance to nearest: Well Foundation Property Line t LEACHING LINE 0 No. & Length of lines, Total length/size FILTER BED 0 Distance to nearest: Well '" Foundation Property Line ` mlh'I I SEEPAGE PITS IJ Depth Siza ii Number a SUMPS Lf Distance to nearest: Well . ' Foundation Property Line DISPOSAL PONDS ❑ } I 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 f employ any person in such manner as to become subject:to"workman's compensation laws of California." Contractors 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 Cal la." 1''✓11,'; li The appli nt m cal u'red inspections. Complete drawing an reverse side, a Signed 1�-+v n� N* 'GR r� f tggt i Tde: Date: _ w i' + 'FOR DEPARTMENT USE ONLY Application Accepted by Date Are, i .E Pit or Grout Inspection by Date . Final Inspe ion b r1 Date Additional Comments: Applicant - Ret r 11 copis to: 3 n oaquin County Public Health Sery ces 3 Environmental Health Permit/Services 445 N`tan Joaquin, P O Box 2009, Stkn, CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED 9Y DATE l • Eli 11PERMIT'NO; 21(REV.f/h e+ � a;�] � EH 142e O ' .1 die