FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

+- APPL'1(:A'A>,. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application in hereby merle 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. Cit Lot Size/Acreage Q Job Address Owner's Name l Address +� Phone OF 4 l0 Z, fig TFddress l i se No, Phone Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 7 DESTR ON o Out of Service Nell ❑ �/� PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER ❑ Ss� ►rltiss DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �t FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public Cl Other n Delta Depth of Grout Seal Type of Grout -�w►r��- -- I ; Irrigation Approx. Depth I 1 Eastern Surface Sea! Installed by Repair Work Done v Type of Pump H.P, __— State Work Done _ Well Destruction ❑ Well Diameter Sealing Material 1 Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADOITION I 1 DESTRUCTION l I (No septic system permitted it public sewer is available within 200 lest,l Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size 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 0 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 subject to workmen's compensation laws of California." Contractor's hiring or subcontracting 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 laws of California." The applicant ust a r I r uire ritions. Complete drawing on reverse side. Signed Title: Date: 10 DEPARTMENT USE ONLYApplication Accepted by � Date I 0__ZM C. __ ___ Area Pit or Grout Inspection by Date_4s eFinal Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'No. INFO g Page 13A EH 13741#EV.tia,sr;A�, / /t11D q EH 14.76 Y 1"'�