FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

0 APPLICATION . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Q0 rA} r of _T-5 City L f Lot Size/Acreage S -, mss/ ^ C Owner's Name (� IIw" �� Address AT-?f �� g�'��' �� Phone�0 Contractor. 69C-6(m - Address�4f +4 MARnN-z License No. TYPE OF WELL/PUMP: NEW WELL tNWt) WELL REPLACEMENT r-- DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ / SYSTEM REPAIR ❑ (Cpr�OTHER G9-1 Monitoring Well (3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �l EkrrACHO 00.2r &4PJS) ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications — ['I Public ❑ Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size -FILTER BED ❑ Distance to nearest. Well Foundation Property Lina SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearsaw Well Foundation Property Line DISPOSAL PONDS ❑ 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 certifies 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 subcontracting 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 applicantr�`call for��aaII��required ins tions. Complete drawing on reverse side. Signed X— Title: 1� -��I�P /I/a Pn Date: ` �,�,eF1/OCnR�(/p/EPARTMENT USE ONLY Application Accepted by �'� '"'" Date AreaC Pit or Grout Inspection by Date Fipal Inspection by Data Additional Comments: rP—r Applicant - Return all cops s to: San Joaquin unty Public Health Se es Environmental Health Permit/Services .Q� 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . FH 13 24IREV.1/x 5i �� Oo u'rs 7 d(,��3g Page I3J EH;