FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

i F APPL I CATI 'OR PERM I T ¢T 3 JOAQUIN COUNTY PUBLIC HEALTH RVICB3 4 ENVIRONN[ENTAL HEALTH DIVISION 1601 E. HA2SLTON:AVE , PHONE (209) ~3420 P O BOX 2009, . STOCKTON, CA 95208 R . (Complete in Triplicate) Application is hereby made•to San Joaquin County for a permit to construct sad/or inetd7l the work hereYn described. This application is made.in ooMilance vith.San Joaquin County Ordinance No.. 549, and 1862 and the`Rules and Regulations of San Joaquin County Public Health Services. I g City Lot Size/Acreage !` { Job Address m l it � 4416 hens Owner's Name Address'pt), Q' Contractor Address I Licenie No.054_ Lgio phon TYPE OF WELL/PUMP: NE ELL WELL REPLACEMENT ❑ DESTRUCTION Ll Out of service well ❑ TEM REPAIR ❑ OTHER C1Monitoring well PUMP INSTALLATION ❑ SYSI 61STANCE TO NEAREST: SEPTIC TANK �— SEWER LINES i':g— DISPOSAL FLD. �� PROP. LINE 5 FOUNDATION . SO AGRICULTURE WELL ALL OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t� n Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing ~ 9 F] Domestic/Private C1 Gravel Pack 0 Tracy Type of Casing 4b ��. Specifications 1 �f,Public !: 1�other n Delta Depth of Grout Seal N 3� Type Of rut S I i Irrigation W'Approx. Dept j I Esstern, Sua rig rface Seut Installed by Repel(Work Done 0 Type of Pump � H,P. State Work Done Well Destruction O Well Diameter; Sealing liateritil i Depth `av] I[� Depth , – Filler (Material i Depth t TYPE OF SEPTIC WORK: NEW INSTALLATION I I- REPAIR/ADDITION`.l I 'DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet-1 J 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 ijj ❑ Type IMfg - Capacity No. Compartments PKG. TREATMENT PLT.C] Method of Disposal a L Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b Length of lines iI Total length/size O FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS <:� ❑ I hereby certify that i hove prepared this application and that the work will be done In accordan_ee with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County - Home owner or licen"d agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall net employ any person In iueh manner as to become subject to workmen's compensation laws of California." Contrector'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 employ persons subject to workman's compensa- tion laws of California.:`. �f The applican ust c IV Or a r ire ins ctions. omplete drawing o reverse side. - /',,, L31 Signed f iIte: � n � L�KL- Date: F� FOFi DEPARTMENT USE ONLY �+ Application Accepted by date LS_! .Area Pit or Grout Inepsctlon by Date Final lnepection by O Additional Comments;;,' A' Applicant – Retum fell copies to., San Joaquin County Public Health Services, Environmental Health Permit/Services !E 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 ��.•!!! IFEENFO lli,. AMOUNT DUE AMOUNT REMITTED CASH RECEIVED Y DATE PERMIT'NO. _ // . EHt3241REV.F��si r � O [Y�� EH 14.20 iT. Ri 4