FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

SAN JC,,,iUIN COUNTY PUBLIC HEALTH S' 'ICES ENVIRONMENTAL HEALTH DIVISIO� 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 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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health � S,e1rvices. y� Jaz �( Job Address /0 N Fri N `.%T — /^�' City r r ,yC,4 Lot Size/Acreage Q r� Owner's NameT_6_CU�A%- �\ Address , +0' � PC�/1E!' ('lam't� � Phone 7"^ S ta?S k0-v A-C- wt�c}S$ C-S"7 �S Contractor_ #-k& it �''+�ts:a Address �l �% z t License No.�i�l�rSfG�/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION 0 Out of Service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ � JrIv�Go )THERX Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK A— SEWER LINES 2 + DISPOSAL FL_O.J"AdA_ PROP. LINE _e FOUNDATION 1@ r AGRICULTURE WELL _hL&_ OTHER WELL�� PITS/SUMPS L�L� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 industrial ❑ Open Bottom PiL Manteca Dia. of Well Excavation /•S Dia. of Well Casing NA I] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing IN_1% S cifications—N A 11 Public t 1 Other rl Delta Depth of Grout Seal Tc ttiL ac-1, ype of Grout M?,g'C,.,-.,. - I 1 lrri0ation —Approx. Depth I I Eastern Surface Seal Installed by ✓ Repair Work Done U Type of Pump NPC — H.P. State Work Done _ Well Destruction O Well Diameter MA Sealing Material 4 Depth Depth Filler Material b Depth N{r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I (No septic system permitted if publi or is available within 200 fee Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms PAYMENT Character of soil to a depth of 3 feet: Water tabl SEPTIC TANK O Type/Mfg Capacity No. Comp�n PKG. TREATMENT PLT. Method of*� Distance to nearest: Well Foundation Property LineSp,j j6#, 1N COUNTY LEACHING LINE O No. b Length of lines A Total FILTER BED ❑ Foundation Property Line SEEPAGE PITS 11 Depth Size Il. Number SUMPS LI Distance to nearest: Well F I 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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 shalt employ persons subject to workman's compensa- tion laws of California." The appli t must call for all inspections. Complete drawing o reverse side. Signed E Date: r Ir FOR DEPARTMENT USE ONLY Application Accepted by Date Area a-- 7 Pit or Grout Inspection by 14601 Im Date �' Final Inspection by 'r LWAC4 Data,-5/;- Additional atos ;- ` Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Permit/Services 445NSanJoaquin,Health OStkn, CA 95201 INFO AMOUNT gqDUE AMOUNT',ceAE��MITTED )CC SH EC VED BY DATE PERMIT'NO. . EH t3•N 111EV.rihsr �L(J '�v /37Z t �j�14-'�j�L ��7 EH U42a