FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION 1-00, D �gll�� • SAN JOAVIN COUNTY PUBLIC HEALTH SERPIC ENVIRONMENTAL HEALTH DIVISION gU�ip 5 1993 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR EM DATE ISSUED PERMIT/SERVICES (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This epplicatiom is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 021WI 6Z,410 77- JR-OAP City t Size/Acreage / Owner's Nana ='SCK �,usf�5� •' �/ / r Phone Contractimia Address q se h1.AkZ= Pt►o 4iW TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER won O DISTANCE TO NEAREST: SEPTIC TANK A46=— SEWER LINES &! DISPOSAL FLO. W A- PROP. LINE l FOUNOATION 30 AGRICULTURE WELL AV&— OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom O Manteca Dia. of Wall Excavation Dia. of Well Casing n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing '� Specifications "— I'l Public 1-1 Other i1 Delta Depth of Grout Seal 3d Type of Grou I I hr4stion ,Approx. Depth Eastern Surface Seel Installed by Repair Work Done U Type of Pump H.P. State Work Oo9s Well Destruction O Well Diameter Sealing Material A Depth �&=AN e Z T Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I t (No septic system Permitted it public savior is 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 O Type/Mfg Capacity No. Compartma is PKG. TREATMENT PLT. O Method of DWposel Distance to noareat: Well Foundation Property Lira LEACHING LINE ❑ No. A Length of lines Total length/site FILTER BED O Distance to nearest: Well Founastion Property Lire SEEPAGE PITS 11 Depth Site Number � SUMPS LI Distance to nearest: Well Foundstion Property Lite DISPOSAL PONDS O I hereby corWyr that 1 haw prepared the application and that the work wig be done in accordance with San Joaquin county ordinances,state laws, and rules and repuletwo of the San Joaquin County Mortis owner or 5corteed agent's sowturs certifies the following: "i certify that in the performance of the work for which this permit is issued, 1 ahail not errEpby any pn in such manner as to becti a subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature Q ten R ft folotving:"I certify that in the performance of the work for which this permit is issued,I shag employ persons subject to workmen's compensa- tion lawe of California." The applicant tions. Complete drswing on side. Signed Title: / �_ ' [�^t"K� �' Date: y� FOR DEPARTMENT USE ONLY Application Accepted by 04 Area frit or grout inspection by Date Final inspection by D Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Savironsiental Health Permit/cervices 3�,p 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED H ECEIVED SY DATE PERMIT'NO. . IN 440,1EEV.,,a s! 89 tri 8 3 EM 11.E