FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT Y J SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` D ENVIRONMENTAL HEALTH DIVISION f ' 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 work herein described. This application is made in compliance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address GS j S • Hac Q��++r4Lr '34� - City c Lot Size/Acreage o.2� Owner's Name So`,�Lern 1�e�c 4..t Ira/tS,rCo. Address OAe f{ork,t 4p1la- Za �Sa•1 Franc.sco Phone (4 k-3) 541 - 2673 `jPECTZIArA 2$2S 6. Hyr�le. 3+. Contractor EY-eLOIZAI-1041:, (-. Address S�ocK�on 1 4CA 9 S ZCS- License No. 51 Z'2 rob Phone(Z--A465`-2 I I Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Xf Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Veli DISTANCE TO NEAREST: SEPTIC TANK N a SEWER LINES d4 DISPOSAL FLD. M PROP. LINE "f X301 K FOUNDATION A' AGRICULTURE WELL�A OTHER WELL: 2000 ' PITS/SUMPS d INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing l-1 Domestic/Private ❑ Gravel Pack7 9 Tracy Type of Casing Specifications Il Public K Other n Delta Depth of Grout Seal Type of Grout ,n I I Irrigation L"Approx. Depth I I Eastern Surface Seal Installed by V \ Repair Work Done U Type of Pump NA H.P. State Work Done Well Destruction Well Oiamoter 1�_ Sealing Material i Depth x� J� ��_ is e� Depth 1 7 Filler Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation wdl serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of sod to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. R, Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS II Depth Size Number ` SUMPS LI Distance to nearest: Well Foundation Property Line 1 DISPOSAL PONDS ❑ ,_I 1 hereby certify,that 1 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 cmtifies the following: "I certify that in the performance of the work for which this permit is issued, I shell not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signeture certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The t mus d for all required inspection*. Complete drawing on reverse side. Signed ,/ Title: 'ro A4 5 e r Date: It - 7-5 2 FOR DEPARTMENT USE ONLY Application Accepted by Date l` Area Pit or Grout Inspection by �,(]� [� '-Final Inspection by Date i 2. Additional Commence: ��L'4Z L/1�`II WA .(�/�[ ,Y�4" 1/1.l� 5 �1/EX , Applicant - Return all copies to: San Joaquin Coun y Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE !! INFO AMOUNT DUE AMOUNT REMITTED CASH-r . RECEIVED BY DATE PERMIT'NO. . EN13-24(11EV.1/ns) EN 116•26