FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION SAN &QUIN COUNTY PUBLIC HEALTH &VICES 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 mode to San Joaquin County for a permit to construct and/or install the work herein described. This application 1s made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Q p / SantQ City Lot Size/Acre e 13.5V / oac!� Job Address�"r`�nc -57"1 Bay-U6% Q r 0Address - r `lUnh Owner's Name � - -= 'C+ --Phone tcS� Contractor 1 �1 Address Po.(�jdy, S License No. 6n 3:?,(o Phon TYPE OF WELL/PUMP: NEW WELL is WELL REPLACEMENT Cl DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Sl•(tn cJ.- Dia. of Well Casing IkeAc 5 Domestic/Private DA Gravel Pack J4.Tracy Type al Casing 4r- 4A PVL Specifications 1-1 Other F1 Delta Depth of Grout Seal 113 Gam.* Type of Grout r'/ A-*' 5&.+ � I'I Public r n I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by,�-.1 t fir•^-✓ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter •.L'lt..�l„ Sealing Material i Depth G .. '1 F�a,�:kr-...•� A.cc.T Depth 2 s ce':1 _ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I avadabseptic le s st m per fitted it public sawer is Installation will some: Residence_ Commercial_. Other Number of living units: _ Number of bedrooms Character of wil to a 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 ❑ No. i Length of lines Total length/size FILTER BED' ❑ Distance to nearest: Well Founoation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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, I shall employ persons subject to workman's compensa- tion lawn o1 California." The applicant must call for all re�/quired he tions. Completes 4lrawing ondeverse side. Signed X ��nl�n� M r �Or" Title: LJeo(LA4I Date: / l FOR DEPARTMENT USE ONLY 7 Application Accepted by o -`�-�C-c�J Dats •� `13 A�re�a� Date SS Final Inspection by -��" ` r "�" -" Onto T Pit or Grout Inspection by --�/L-JL Pe Additional Comments: �D /� YJ/1 l�e/1.1.0/1 fT�r/n%L UlC' {{.S ®�1 {N PI WZ Applicant - Return all copies to: San Joaquin County Public Health Ser ices Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 NFD AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. Page I3f x311 �r f 3 �S aoss7 d • IM 1}aa IREV.1/R5) EN 16L