FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION SAN 4kQUSN COUNTY PUBLIC HEALTH I&VICES ENVIRONMENTAL HEALTH DIVISION C 445 N SAN JOAQUIN, PHONE (209)468-34;2,Q_ C P 0 BOX 2009, STOCKTON, CA 952011 n PERMIT EXPIRES 1 YEAR FROM DATE ISSUED # 'v (Complete in Triplicate) Application is hereby mode to San Joaquin County for a permit to construct and/or install the work herein describe . application is made iic,nyI�compliance with San Joaquin County Ordinance No. 5L9 and 1862 and the Rules-and_jiegulations of San Joaquin County JVdal2 th15gyiCaiievron Job Address 6142211 W. IIP..adddollc��k Place CityLodi ` Lo � �I e P . O. Box 2180 L 957 F� Owner's Name Flag City Inc. Address -p -, Lodi 9cr5241-op— Phone -6 Contractor Spectrum Exploratj@,�,5 2825 E. Myrtle Street ense No, 512268 Phone 465-8712 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 7 DESTRUCTION G Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERS] (l�°nitoring Well DISTANCE TO NEAREST: SEPTIC TANK +6;pSEWER LINES "f SD DISPOSAL FLD. PROV2 INF Borin S FOUNDATION 4-52 — AGRICULTURE WELL 'rte OTHER WELL r PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS NiO'^' ::r 2" ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing pvc Specifications i'1 Public n Other M Delta Depth of Grout Seal (nD, * Type of Grout bent/Cemel t I I Irrigation 25Approx. Depth I I Eastern Surface Seal Installed by See Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material E. Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public Wwer is available within 200 feet.) inaiaiiahgn wtii aerve��T+lue::Ga � ..aT Number o1 living units: _ Number of bedrooms r>\ Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line (� LEACHING LINE ❑ No. 8 Length of lines Total length/size r\1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby comity 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 lot 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 signatures certifies the 10 ..1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman'a compensa- tion la ( Californ17 The ap licant must II for all req ed i cti of drawing on reverse side. Signed ;de: Manager D81e: 8-31-94 FOR DEPARTMENT USE ONLY Application Accepted by �— Date Area Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: "✓ f Z 6 Applicant - Return all copies to: San Joaquin C unty Public Health Services D Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. cJl INFO Q� ��f 9 A E. 1)]4 IREV.I i X 51 y .C� (�g �,I L. / "r� -9 EH la.]a