FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JUIN COUNTY PUBLIC HEALTH S4ICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 PA Yi%j tV l P O BOX 2009, STOCKTON, CA 95201 RFCF1 VP f:,'g PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AU(3 13 1992 (Complete in Triplicate) SANJOAQ01N rr,t� � Application is hereby made,to San Joaquin County for a permit to construct And/or instAll the 00m,4�'V11 1 cn tllfFil>3 application Is made in ccuVliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulati 4VSk'Pj Joaquin County Public Health Services. Job Address 1 Sol i7aC_ �.rdY �}C'�V 'G. _ City �Cxati^r Lot Size/Acreage 7 Owner's Name G' J `"ddress Z� 13 AFL DctiMxs&53 ��• Phone `` C S7•. Contraclor Address 010 0'0:-Ikn .611.t tig-'I" -'A License No.foZ`� 7�� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Ll Out of Service Nell ❑ PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER)9.5,,j M°tutor Well C1 DISTANCE TO NEAREST: SEPTIC TANK __1 t7ts'� __ SEWER LINES Zr DISPOSAL FLD. PROP. LINE 3 � FOUNDATION _lGU AGRICULTURE WELL � OTHER WELLfl@�'ro PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private 0 Gravel Pack Ll Tracy Type of Casing_ Specifications I't Pubfic Y.VOther q9 Delia Depth of Grout Seal Type of Grout I I Irrigation ZOIApptar. Depth I I Eastern Surface Soul Installed by Repair Work Done L1 Type of Pump H,P. Work Done Well Destruction 0 Well Diameter Sealing Material i DepthV19— Depth Filler Materiel i Depthi—AffAe TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION I I JNo septic system permitted it public sewer is available within 200 feet,I Installation will serve: Reiidence_ Commercial____, Other Nbmber of living units: Number of bedrooms Character of soil to s 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 0 No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Numbet SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared thit; 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 certifisi 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 iiaued, I shall employ persona subject to workman's compensa- tion laws of California." The applicant mus c r all quired inspectioni. Complete drawing on reverae side. Signed r Title: �✓�� Date: ~" - FOR DEPARTMENT USE ONLY li3t9 Application Accepted by Date v Arae Pit or Grout Inspection by Data Final Inspection by Date Z Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmontdl Health Poimit/Services n�� 445 N San Joaquin, P 0 Baa 2009, Stkn, CA 95201 G INFO AA�M�OUNT DUE AMOUNT REMITTED CK ECEIVED BY DATE ry PERMIT'NO. • EH IJ-20IAEY.iiesr `-� ! ,Lam/ NO�