FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH WRVICES ,y ENVIRONMENTAL HEALTH DIVISION ✓ ��jr� O 1.601 E. HAZELTON AVE. , PHONE (209)468-3 P O BOX 2009, STOCKTON, CA 95201 Ji`t ti 1 logo . I EBR,,�[,IT EXPIRES 1 YEAR FR06�_DATE ISSUED j (Complete in Triplicate) i Application is hereby made to San Joaquin County for a permit to construct and/or install �tgg i'bed. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the L�d11�Ilone of San Joaquin County Public Health Services. Job Address 91 East Thomsen Road City Lathrc)n_ Lot Size/Acreage 'A aCrpc I Raymond M. Quaresma 26290 South Union Road 209=823-1455 an Owner's Name Address eco, Phone _ Contractor Westex Address P•O• Box 1664 W.SaC License No. 5521.9$ ._ Phone 91 6-371—U18 j TYPE OF WELL/PUMP: NEW WELL ❑ -- WELL REPLACEMENT ID DESTRUCTION 0 Out of Service WellAj C1_. PUMP INSTALLATION O SYSTEM REPAIR ❑ Ott [) HER Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK�10 f eegEWER LIN&OO feet DISPOSAL FC�IOo f(OIP. LINE'/!_0_f eet FOUNDATION'>!0 �eeXGRICULTURE WEL)ID-U_f_tOTHER WEL IDD_Lt PITS/SUMP LfW feet INTENDED USE TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'] Public }¢jkOther • ' n Delta. Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seat installed by Repair Work Done 0 Type of Pump H.P. State Work Done Soil Borings Well Destruction ❑ Well Diameter Sealing Material A Depth Croat- frnm toira.1-_8 pth to stir ace Depth Filler Material & Depth gra.d e TYPE OF SEPTIC WORK: NEW INSTALLATION I I- REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 leet.l 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. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size j FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1 - Depth Size Number j SUMPS CI Distance to nearest: 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 canities the following: "I cavity 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." Contractors hiring or sub-conrracting signature certifies the following: "I canify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa tion laws of California." ' Theapplicant must call for all required inspections. Complete drawing on reverse side. I Signed Title: S`er,av, SVkoCIC (1- 0/o Data: ;FQMA��/NT USE ONLY k: i. by Date Application Accepted O Area I Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return a.11 copies to: San Joaquin County Public 'Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT NO. INFO CASH lI • EH 13.74(REV.r/it 5) EM:4.26, 3 S . cl '� ��C7(oa+ / V �° �'�•��7b '�` gyp`"