FIELD DOCUMENTS_FILE 2 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUER (Complete in Triplicate) Application in hereby tide to San Joaquin Colony for a permit to construct and/or inatalI the work herein described. This application it trade in ecapllance with San Joaquin County rdinance No. 5 and 1862 and the Rules and Regulation* of San Joaquin County Public Health Services. CPQLlC F�lA_/7 Job Addrex Z �c 14�� City/ Lot Size/Acreage Ownor'e Nana jC_ �� Address C_ 5L /t 20Z �� --- Phone Contractor s dress � ��.��1�� License No.&=1-,i- _Phone j TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT n OESTRUCTIO t of Service Hell O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Vonitorina Well O DISTANCE TO NEAPEST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Irtdurtnol ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wed Ca^,ing n Domoatic/Privato ❑ Grevcl Pack ❑ Tracy Typo of Casing Spocificationna 1'1 Public fl Other n Delta Depth of Grout Seal Typo of Grout I I Irrigation _Approx. Depth I I Eastern Surfaco Seal Installed by Repair Work Dora C] Typo of Pump H.P. Statc Work Dona c, Z27_ � &F-74J_ Well Dectruetion � WC'J Dicmator �f Sealina tatorial 6 Depth f i��,, �p�7 Dcpth �:4�' �'- Filler raterial 6 Depth _� rar / k-Lal ce xv TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I lNo septic system permittod if public sewer a available within 200 fact.) Inotoatotion will t orwo: RtAfideneo_ Comrmrcial_ Other Numbcr of living units: Number of bcdrooms � Chacctcf of to to n dt,�pth of 3 f=t: Wator trbb depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compertrranm PKG. TREATMENT PLT.❑ Mothod of DiepowJ is Dbtcnco to naereat: Well Foundation Property Lino TEp LEACHING LINE Cl No. b Length of lines Total tongth/sizo t \ FILTER BEO ❑ D ztcnco to nsveat: Well Foundation Pfopony Lino 1� SEEPAGE PITS I I Depth Size Number SUMPS LI Datotico to n r—_t: Well Foundation Property Lino (� DISPOSAL PONDS O ` 1 horcby sonify that . hcvo prepared this application and that the work will be done in accordance with San Jotauin county ordinances, stoto laws, and _ rul-z end reCulationo of the San Joaquin County Homo owrar or ficensed cgcnt'a c pv=turo conifer the following: "I certify that in the porformanco of tho work for which this permit io itz=d, I rhaB not cmplay any pacon it cueh mcnnsr co to become cubpet to workmen's componaation Iowa of California." Contractor's hiring of sub-contracting tignatum ccnW=tiro fa"..owirlp:"I certify thet in tho porformcneo of tho work for which thio pormit is icauod,1 shall employ percono tubpct to workman's eomponco- T tion Lama of Ccllforrk." Tho t pp"`aCrlt is rc�uirt - ions. Complete drawing on rove �sido. Sigrad itlo: Dcto: FOR DEPARTMENT USE ON nF �.� k.pplFcotlon Acceptcd by nate i ` v / Arca �f Pit or Grout Incpoction by Data 14 Final Inepoction by _ Data Additional Conwrtrnu: Applicant - 3oturn all copies to: San Joaquin County Public Health Services Environmental Health Permit/Serviceo 445 N San Joaquin, P O Box 7009, Stkn, CA 95201 FEE AMWNT Dal@ AMOUNT'REMITTECASH O K RECEIVED GY DATE PERINIT'NO. . EN 13-27 IMV,t,a,tINFO �"=3 �D 6� 521 I'W1 1- V.q �2 42,31 IN 1427 !-