FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERM I T f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION 1601' E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 f PERMIT EXPIRES 1 YEAR_FRPM DATE IS5VED i (Complete in Triplicate) i 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 Servii'es. paelVE� � I Job Address 3 3 NAVY P P_IVE STDC_K-TDq ST. AND — City SreltkTbd Lot Size/Acreage Z•4f A+~2 S `4,I ! Owner's Name BL 11140 E Qt'll " C'S Ir16 r Address 3 3 QUAIL LAMS- !e'er--- Phone 2-01- 15-7-Z7-41 S PECfT1C,U I License Contractor Address Z 2S E M`��t-� S`• License No51Z.Zrp3 Phoneme - 4B 135F5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 A Monitoring Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 0TH R ., 501,1_ �D12JhIC�S[7 DISTANCE TO NEAREST: SEPTIC TANK! 7 56-44- SEWER LINES > Sti•f1 • DISPOSAL FLD,>SD14- PROP. LINE FOUNDATION �l AGRICULTURE WELS • OTHER WELL75D'P4• PITS/SUMPS Sp INTENDED USE TYPE 4FAWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ O m ❑ Manteca Dia. of Well Excavation Dia. of Well Casing N Cl Domestic/Private ❑ Grave Pack. n Tracy Type of Casing H A Specifications f"l Public 1-1 Other n Delta Depth of Grout Seal 1.544- Type of Grout C kt;J T ' I I Irrigation —.Approx. Depth t I Eastern Surface Seal installed by Repair Work Done U Type of Pump�� H.P. State Work Done el Sealing Material & Depth G` EAT- IY6II Destruction ❑ Well Diamlt ONT " eMON Depth Eiller Material i De th f.1f7L� V,, I } TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 lest. installation will serve: Residence __"ICommercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg "f' Capacity No. Compartments PKG. TREATMENT PLT. El 1� Method of Disposal I Distance to nearest: Well Foundation Property Line 4 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line f JHL19M-9 SEEPAGE PITS 11 Depth Size _ Number T#L HEALTH SUMPS Ll Distance to.nearest: Well Foundation Propertyine�ER��C�s DISPOSAL PONDS Cl ! �I 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 �i 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, f shall employ persons subject to workman's compensa- tion laws of California." d The applic st.call for I yAquired ins coons. plete drawing on reverse side, 2 G� 4514& Signed Title: Date: f Lm • FOR D RT USE ONLY -7 4 Application Accepted by Date v res Pit or Grout Inspection by Date Finall� Inspection by Date 7�� Additional Comments: __ v 1Z .C� SAA Applicant - Return all copies to: Sen Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 lM1F E AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED 9Y DATE / PERmi- N0. a EH 13-2�IRE'V.iinsi 75 / �3 �f ZU q�f ,,yy4-211 tc`1-l 1 i