FIELD DOCUMENTS_FILE 1 - Laserfiche WebLink

Home Browse Search

ApPLICATTON 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 =IRES 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 a+70/ N• lJl ljo i Ljgv City �+cx'/ffarl Lot Size/Acreage Owner'sNamee `o � -/traw! r/1o0'aT;00 Address 7yl N• 13lac So /� ne 19u<�. Phone �� 'y�� Contractor I�AIJ�'ed �.orISU 7�i114S Address .?0q0 Ckl'rema,4 01-. License No. S/a0/O Phone G/9'a7s"6�� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION r SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 2/CIC' 'Pron+ ' DISPOSAL FLD. -21-6-7-,01-4/00 ROP. LINE -;>- 4 AGRICULTURE WELL / 7�OTHER WELL50�c PITS/SUMPS Na INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C� Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatione� Dia. of Well Casing nah Domestic/Private Gravel Pack ❑ Tracy Type of Casing axc1:4. SCN '/O PUC Specifications I'I Public Cl Other n Delta Depth of Grout Seal 62,f5P,-e4 Type of Grout 00ncr'4J-L I I Irfipation �1 Approx. Depth I I Eastern Surface Seal Installed by I1 GnJu IT4N� (vii Repair Work Done U Type of Pump N•H• H.P. N State Work Done _ •S yr l Well Destruction ❑ Well Diameter 4 41G� Sealing Material i Depth / est Fon. 6 7-70 ee+ Depth QO ill--e4 Filler Material i Depth #3 SRNt� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTgYATV I I Mo septic system permitted if public sewer is Eble within 200 feet.) Installation will serve: Residence_ Commercial_ Other R�'C�1V>� Number of living units: Number of bedrooms RECEIVED Character of soil to a depth of 3 feet: M QY 1 � M Water table depth SEPTIC TANK ❑ Type/Mfg Ca$iaN1NP. Compartments PKG. TREATMENT PLT. D PUBLIC HEALTH SERVI( od of Disposal Distance to nearest: WellENdation MENTAL HEAI�,bpp gym Foundation LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sim A Number SUMPS LI Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line 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 w certifies the following: "I certify that in the Performance of he work afor which eth thiswet son siswedof !loshall emloContractor's hiring or subcontracting signature tion laws of California." p employ persons subject to workman's compensa• The applicant must call for re s c n plate drawing on reverse side. Signed 1 Title: _ Pry s; e n I Date: 3 9 3 FOR DEPARTMENT USE ONLY Application Accepted by u � _ 2 Date �� J (�i Area Pit or Grout Inspection by Date Z Final Inspection by �LS �1 / Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public health Services 0 Eavironmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT NO. EH 14.20 IREV.iinsi Q EH `5 -16-293F3 F 14-20 .1