FIELD DOCUMENTS_FILE 1 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN dt)AQUIN COUNTY PUBLIC HEALTHOERVICES 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 theRules and Regulations or a S Joaquin County Public Health Services. �/�� , 1 11v1 n� v L 1��`� 1� \,J�JL.L City� Lot Size/Acreage Job Address �. � " 11 ./��/ Address zg � � Phone Owner's Nameu- t �� -7 'M CJ` Phone L4 p� 4 Contractor iC'�1C�yCLt Address License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well —�— PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER ❑ C��.tortitoring Well DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS _ FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing I f G Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavalio Specifications— 71 Type of Casing_ •T V ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal M• �y Type of Grout !'I Public ❑ Other I I Delta m I i Inigation _Approx. Depth I I Eastern Surface Soul Installed by -11 of Pump M.P. __ State Work Done Repair Work tons U Type Sealing Material i Depth Well Destruction ❑ Well Diameter Piller Material a Depth Depth TYPE OF SEPTIC NIORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION I available etic Yin witYlin 200 feet.) if public sewer is Installation will serge: Residence__— Commercial__ Other ti Number of living units: —:...Number of bedrooms__ Wstar table depth_ Character of soil to a depth of 3 feet: - No. Compartments SEPTIC TANK ❑ Type/Mfg — Capacity-- Method of Disposal PKG. TREATMENT PLT. ❑ Line Distance to nearest: ell Foundation LEACHING LINE ❑ No. ngth of lines Total length/size Property Line FILTER BED ❑ lstance to nearest: Well Foundation SEEPAGE PIT if Depth Size Number SUMPS -- LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ e work will be done in accordance with San Joaquin county ordinances, stela laws, and I hereby certify that I have prepared this application and that in rules and regulations of the San Joaquin County Horne owner or licensed agent's signature certifies the following: 111 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workmen'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, 1 shall employ persons subject to workman's compensa- tion to ofifornla:' The a licant ust call f r of req trod pgotions. Complete drawing on reverse side. Date: Signed Title: D1 �'E OR DEP TMENT USE ONLY a q �Z, CIL Area -- Date Application ccepted by Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services F35 Environmental Health Permit/Services IJI 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FFE CK RECEIVED By DATE PERMIT-N0. AMOUNT DUE AMOUNT PEMITTED CASH q / Q .0a 19q0 — ti 1 1 -! I . EH IY]3 IREV.11 n m �` H 14-23 ---