FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 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 is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. (.i1Ur1 4acx) ' JI Job Address as 474} - R,AAP- SP RCfCf �ZC%� City rC Lot Size/Acreage �3 coo S� T'1• l � ^ ' 1 Owner's Name ARL-to ��T`address �LL.�L'7>)X '5210 "YA" ll"tCf Ylt'C2 _ Phone Conlraclor 6 0 . 0 r Addresslfn Sft Ilncf t'aL drl '(+ License No.5`030-S- Phoneytil TYPE OF WELL/PUMP NEW WELL jd V, (- WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION O CXfVfu'h`9YSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK AM SEWER LINES ��yy DISPOSAL FLD. PROP. LINEsrC' /Mjp FOUNDATIONSLlMe.lAGRICULTURE WELL dr1J— OTHER WEL PITS/SUMPS &i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fil Ll Industrial ❑ Open Bottom F1Manteca Die. of Well Excavation.1 r1 Dia. of Well Casing i t ❑ Domestic/Private ❑ Gravel Pack ATracy Type of Casing_9Cl'i ll7 PVC__ Specifications I'1 Pubfic fl Other n Delta Depth of Grout Seal is-4L) Type of Groutbe,- I I Irrigatwn 4;6 6 Approx. Depth I I Eastern Surface Seal Installed by Puik-11 r finea IL Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I Septic system m 1ee6ted if public sower is Installation wilt serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 faaa Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Dispose( Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. d Length of lines Total length/size _ FILTER BED ❑ Distance to nesresr. Well Foundation Property Lina ...`� w SEEPAGE PITS 11 Depth _Size Number ,....rte^r7 SUMPS LI Distance to nearest: Well Foundation Property Una (J`' ' 1�'G 1Tv 0 DISPOSAL PONDS ❑ - 1 hereby cartity 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 Horne owner or licensed agent's signature certifles 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 certilies the following: "I cartity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion (awe of California." The applicant must call 1 a quked inspections. Complete drawing on reverse side. - G`/ �'��yrrr� CYt / O�o; 97� Signed K r / / Title: �— il V6 Date: FOR DEPARTMENT USE ONLY !/ c�?//"1� Application Accepted by Date a T Area 7Jy Ph �� or Grout Inspection by QI - �'O� Dace �' �2 Final Inspection h-ns-pection bV Date Additional Comments 'L� ° Applicant - Return all copies to: San Joaquin County blic Health Services 3500 Environmental Health Permit/Services ST 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. EH 1124 I aEV.I r sal r �� EN 14 a