FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION 1647 SAN JOAQUIN COUNTY PUBLIC A _ ENVIROMIENTAL HEALTHN 445 N SAN JOAQUIN, PHONE Ml M � P O BOX 2009, STOCKTON, 01 PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED (Complete in Triplia4W 1.1 Application is hereby mads 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 Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin Co ty Publi�V` Sery Job Address City SIM oP Lot Size/Acreage I Acfz�F_ , Owner's Name f�tb►►k r,IJEF S 1 DBA-ft, Address; E(! Dog-,*on 5► - Phone Abs- b r J 1 O p C� ContractoAl-w Deal 1&fbAIDV4ddress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ AO,�T,HER ❑ Monitoring Well bt DISTANCE TO NEAREST: SEPTIC TANK �_ SEWER LINES _1!y0 I DISPOSAL FLD,NA PROP. LINE _ FOUNDATION _ AGRICULTURE WELL I�A_ OTHER WELL PITS/SUMPS ) INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation lY1Gl4 Dia. of Well Casing KDomestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ INC, Specifications I'l Public I1 Other n Delta Depth of Grout Seal Z! f6t Type of Grout'POEMND I Irrigation Approx. Depth QF.Eastem Surface Seal Installed by T ltdS Ff bELL 19OX Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material iTF Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation rv�Ilesid�_ Commercial_ Other Number of living unber of bedrooms Character of &oil to ot: star table depth SEPTIC TANK ❑ Type/Mfg Capaci No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. A Le of lines Total length/size FILTER BED [7 nce to nearest Well Foundation Property Line SEEPAGE Pl 11 Depth Size Number SUM LI Distance to nearest: Well Foundation Property Line D SPOSAL 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 peiformance 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 taws 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 applicant must �call lffor �alll,rre�quired inspections. Complete drawing on reverse side./� � Signed X4rt-w, `.s1 1� !h �^' '"- Title: 'Fitt lic 'f &C-D L"-Tr Data: Z— —9 y �M �f� //►y � FOR DEPARTMENT USE ONLY Application Accepted by 1t 1P3� A _ _-__ _ _ Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services JE�r O 1 Environmental Health Permit/Services hJ 11 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUN�T7REMITTED C_*0# RECEIVED BY DATE PERMIT'NO. . EH 13.24(REV.1 5) g Cf I� 1 54- io � 21 /_ct EH 14-20 1 l IQ