FIELD DOCUMENTS CASE 1 - Laserfiche WebLink

Home Browse Search

APPLICATION _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-3420 P O BOX 388,STOCKTON,CA 95201-0388 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to 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 Development Title Section 9-1110.3 and Section 9-1115.3 andel the Rules and Regulations of San Joaquin County Public Health Services. Job Address �7 30 5 Q p �� (L J � K��l ity��l�� I'°t Size/Acreage Owner's Name �K <<Y�� Address /'�' i hone Contractor Mo 5— Address/'y' Aww, A License No.472/,,?/Z_Phone f5-,z -9ss TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER P'�,«o rittg N� � Well C3DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES A DISPOSAL FLD. PROP. LINE JE FOUNDATION AGRICULTURE WELL = OTHER WELL �� PITS/SUMPS CIL/ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS '/ �1 ❑ Industrial O Open Bottom O Manteca Dia. of Well Excavation 7 Dia. of Well Casing /" CI Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ A11.4 Specifications /.)- I.1 Public ('1 Other 171 Delta Depth of Grout Seal S/ Type of Grou I I Irrigation —Approx. Depth NdEastern Surface Saul Installed by -- — Repair Work Done U Type of Pump H.A. State Work Done_ Well Destruction O Well Diameter Sealing Material i Depth Depth _ Filler Material i Depth r r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AOOITION I I DESTRUCTION 1 I (No septic system permitted if public sewer is \P available within 200 feet.) Z Installation will some: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ,y SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal C, Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- tion laws of California." The applicant_Must c 11 I required ins tions. Complete drawing on reverse side � 1T/�/ Date: c Gs Signed Title: _ FOR DEPARTMENT USE ONLY ' Application Accepted by �r-"'��^ Date Area I Pit or Grout Inspection by Date—?h-31' Final Inspection by ` Data Additional Comments: Applicant - Return all copie o: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 3 l7 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO 4/' CASH /`} • EEm N 13.24 IREV.rigsr �f oc �{ 7 i•� ,�5� AK T-7/ IGq *1)t -r7q a