FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

SAN JUIN COUNTY PUBLIC HEALTH S,,wWICES 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 in hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This application 1s made in compliance with Sat Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. A Job Address 8/�� • BbS��+ri"�'9 LOOP X0r City 71tA"_—y Lot Size/Acreage/y c�s.�rC i60. $O X 3 11 1 Owner's Name WJZV MRN S7"�NE Add ss Nafl ESrti 4M.4 gs 6n 53 Phone CV-564V _ 2 29 t M 1 qts WO�I tj 7�Cv8 cM)445- 717- r !S�ZOO�$ Contractor SPECTRUM Address License No. Phone TYPE OF WELL/PUMP: NEW WELL Z WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM EPAIR ❑ OT ER O Monitoring Well X I,� / r SK DISTANCE TO NEAREST: SEPTIC TANK �T SEWER LINES N DISPOSAL FLD.�� PROP. LINE FOUNDATION 5` AGRICULTURE WELL N OTHER WELL_q= PITS/SUMPS 1� INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS tt n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing %Z [I Domestic/Private ❑ Gravel Pack Tracy Type of Casing-PVC, It, Specifications I'I Public (Other n Delta Depth of Grout Seal 5 Type of Grout NXA' I I Irrigation -l�r Approx. Depth I I Eastern Surface Seal Installed by /�F9/�/1~ r�•� Repair Work Done ❑ Type of Pump H.P. State Work Done_ vv Well Destruction ❑ Welt Diameter Sealing Material & Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is C available within 200 feet.) G. 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 PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. fi Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 workmen's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following:"I comity 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." //////'''►►►►►► The applicant mus all for all requir cti n �Trawing on reverse side. Signed x c of Title: G G �OZ 3 Date: - Aq /J FOR DEPARTMENT USE ONLY a // Application Accepted by ' ' `� - Date ' / Area C1W Q Pit or Grout Inspection by Date Ills Final Inspection by Oats Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Ser es / Environmental Health Permit/Services �� 445 N San Joaquin, P 0 Box 2009, Stkn, 95 FEE AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE PERMIT'NO. INFO . EH 13.24111EV.1/AW � oo Al.IM• EH 14�a1 1. 00 92-^/�j lyS