FIELD DOCUMENTS CASE 1 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 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 vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �hJ�T1['gT1orJ FU— Job Address .34-2-Z 5. 9L DnE43>0 Sr 343o �.EL icy STbGI "t9'/V Lot Size/Acreage G �. Owner's Name �Pr►`1L 41_ �e �nl Address 00• �x ( �(� STol >J r CA Phone / �/3 75 Contfactor�A)D&L9;7, 8A -Address I'Ea W A% C 4- License No. S� Phone9Sy6r"'6Z&4 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK W4_ SEWER LINES 76/ DISPOSAL FLD. N11Ar- PROP. LINE 16!� FOUNDATION 7o r AGRICULTURE WELL L44— OTHER WELL SO PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS * Industrial O Open Bottom 0 Manteca Dia. of Well Excavation $ Dia. of Well Casing Z K N * Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Pu I'1 Public n Other n Delta Depth of Grout Seal -1,0 Type of Groutl✓+�r I I Irrigation _..Approx. Depth Eastern Surface Seal Installed by r--4-JA Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter T Sealing Material 4 Depth Depth �a7 Tiller Material & Depth 1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public 64r^w is v available within 200 feet.) 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. ❑ Type/Mfg Capacity No. Compartments r� O PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line /1 LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 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 4 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 terrify that in the porformancs of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant t call f r all required inspections. Complete drawing on reverse side. / O Signed Title: 4;5�, T ��7` Date: FOR DEPARTMENT USE ONLY p Application Accepted by 4eDate (0/1 Area Pit or Grout Inspection b�y1, � AJ l Date� Final Inspection by !Q C`''�`aQ� Data ��17 Additional Comments: IU � �ui`fJ cJ 61, Applicant - Return all copies to: San Joaquin County Public Health Services � Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO EEE AMOUNT DUE AMODUN((/TRREMITTED CASH CK RECEIVED BY 9DATE PERMIT*NO. . EN 13.24(REV.I/A5) /)�� (� /Ps 3 ��/ 4 G 3-/r%(/' EN 14.2 C/ CCG`