FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATIONSV � Jc aNc d-C,�.�\ M CPIVICfiS SAN � � L ENVIRONMENTAL Y� Pd-ALl 445 N SAN JOAQUIN, PHONE (209)468-3420S AJVSA P 0 BOX 2009, STOCKTON, CA 95201 Qtk l ro PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ( _ (Complete in Triplicate) work herin described. Thi Appllcstlo�mede to San Joaquin Countfor Counte rmit to nNoruct 5k9 ando1862saand thee eRulee ande eRegulations of Sans application is made is compliance v1�HGen©Joaquin YOrdinance� Joaquin County Public Health Service ./ Lot Size/Acreage 70�.O AC¢v'�S Job Address -M2 1 StiP.ROE 1�eboT 1Zf5C!'c IZ C7Ai1 city �'r'" Owner's Name u '.rfo EAy,F-S (-tpo _ Address tJ�A Phone Contractor Cny1t QALL-t I`)C2 Address`12 8ER2V �2Wt 1?� E�License No. '851 b S Phon� - TYPE OF�P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION.❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well {� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing P. f asin Specifications 71 Domestic/Private ❑ Gravel Pack ❑ Tracy9 Type of Grout-- I'I Public 11 Other fl Delta '� 1A,1h0OfCGout SealI I Irrigation _Approx. Depth 11Ester \v) ace Seal Installed by H P State Work Done _ Repair Work Done ❑ Type of PumpSe: ing Mnterlal i Depth - Well Destruction ❑ Well Diameter Filler Material i Depth -- Depth J TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I availae tic systethin m reined if public sewer is 0 feet Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Ul --- Water tale dept Character of soil to a depth of 3 feet: No. Com partments - SEPTIC TANK ❑ Type/Mfg C cl y Methodl PKG. TREATMENT PLT. ❑ Distance to nearest: Well Fo ndation Property Line Q(� .. 1„rl n _ t� �.,[ CIJM.Cx 1.lLEACHING LINE ❑ No. & Length of lines Total length/sizeFILTER BED ❑ Distance to nearest: Well a da n Property LineSEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well oundation Property Lin DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, st , 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 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 applica t must c 11 i9 all required inspections. Complete drawing on reverse side. Signed Title: 'a "r Date: In- 79-96 FOR DEPARTMENT USE ONLY Date Area �Nt r Application Accepted by ,,,,,r p ftl Pit or Grout Inspection by - Date Final Inspection by _ Date (P /'-- W�lls ao eo�er�1r111e a borl rou a� OA 43SOf L138� Additional Comments: ) 11 G .may �,� E rte(' q.�e �.}�� _ 5p g 1'� / Applicant - Re�t�Yi r�'`�1S cbpi�s toe rEnv ronmen® CoHealth Perm HB ervicervlces Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 ? IFEENFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BV DATE PERMIT NO. r�Qoe 13A . EH 1I-N IREV. Page EH 1416