FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

A.PPLICATI0N FOR PERMIT SAN o QUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION l„ 445 N SAN JOAQUIN, PHONE (209)458-3420 P O BOX 2009, STOCKTON, CA 95201 !� 4i PERMIT EXPIRES I YT&AR FROM DATE ISSUFsD j (Complete in Triplicate) r, q Application is hereby made to Sam Joaquin County for a permit to construct and/or install'the vork herein described. This application is made in cotq�liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Josquin County Public Health Services. Job Address �2"� 4 ;��r_ 4\ MRtA,�_ City � � Lot Size/Acreage _zoo!WOO J Owner's Name�'� Address •� + © ! r "1 7e 6v.3 1 Phone �" ��y�� ! �'j S'2 F&—_,94 T-y $S(aria! Contractor �� vllCti 11Ad ss t till+ License No.!(O Phone to TYPE Of WELL/PUMP: NEW WELL 0 WELL REPLACEM DESTRUCTION 0 Out of Service Well ❑ i PUMP INSTALLATION ��0 SYSTEM ,��REPAIR�� ❑ OTHER � 41 "1" toring Well L7 DISTANCE TO NEAREST: SEPTIC TANK 415 SEWER LINES L�1� DISPOSAL FLO PRO"P� Sr IL FOUNDATION _ AGRICULTURE WELL _A OTHER WELL PITS/SUMPS �Ll - HINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C:1 Domestic/Private ❑ Gravel ack ❑ Tracy Type of Casing_ Specifications Il Public 10 Other r�� n Delta Depth of Grout Seal Type of Grout III 000 i 2�Q Approx. Depth I l Eastern Surface Saul Installed by e r Work ne Type of Pump H,P. State Work Done Wall Destruction O Well Diameter Sealing Material i Depth / II Depth Filler Material i Depth (" VO An __L fl l�vl TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic,system permited if public sewer is 1 available within 200 feet.) Installation will serve: Residence Commercial— Other Number Of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal !t Distance Rn nearest: Well foundation Property Line I � LEACHING LINE CI No. 8 Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line J SEEPAGE PITS I I Depth Size Number 4 SUMPS LI Distance to nearest: Well Foundation Property Line w DISPOSAL PONDS 0 I 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 oemifies 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 persons subject to workman's compensa• tion laws of California." The'applic t must all r ate sd inspections. Complete drawing on averse side. r' t Speed Title: Date: 61 a FOR DEPARTMENT USE ONLY t i Area Applir:atton Accepted by Date M1 Pit or Grout inspection by ae �� Final Inspection by Date 'l Additional Comments: /ipplicant - Return all copies to: San Joaquin County Public Health Services R Environmental Health Permit/Services r f 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE I INFO AMOUNT DUE AMOUNT REMITTED CASH Cr if RECEIVED gY DATE PEERMIT'N/O. i . Eart37lTREY. bo I0Lf ,;�a 00,g1�