FIELD DOCUMENTS FILE 1 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMITf �-�� j Q 7 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. PAYENTIRONMENTAL HEALTH 20 9, STOCKTON, CADIVISION 95201 P O BO% � RECEIVED (209) 468-3447 . OCT 1 1493 PERMIT E%PIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN COUNTY (Complete in Triplicate) AppllMl(>UC HE&A*S&WUi San Joaquin County for a permit to construct and/or install the vork herein described. This &&WP3NMEW44+EAaT+4x"iWW vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public health Services. G Job Address .2-3 1 J' Alo, G��Mdd 2 'City JT4Ck-7'OAJ Lot Size/Acreage d•IC Owner's NamoS+-ebb 1 IbIPH47,ne �Adddrress523Z He.wet AOe=,Sic-<e-� nJfS?07 Phone 4.77 -t' M d 3 Pt uebe /2oc 4 ( 9 1 _ Conlracto � � �rt�n.. Address O ela C4 9S�I License No.�dtv[,"70 Phone . 76-7 TYPE OF WELL/PUMP: NEW WELL O V ELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service hell ❑ PUMP INSTALLATIIO�N, O SYSTEM REPAIR O OTHER j8( Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ZS' -1-�� DISPOSAL FLD.NZ4 PROPLINE 5:' FOUNDATION /a r AGRICULTURE WELL 1_-A— OTHER WELLN/& PITS/SUMPS z �iA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial O Open Bottom O Manteca Die. of Wag Excavation 7�' 4' Dia. of Well Casing r Domestic/Private. O Gravel Pack O Tracy. Type of Casing oc- Specifications C1 Public nit that O Datta Depth of Grout Seal Type of Grout L^/�>�• tJ Irrigation11 Approx. Depth O Eastern Surface Soul Installed by Repair Work Done U Type of Pump H.?. State Work Done _ Wall Destruction O Well Diameter S•ealin6 Material i Depth Depth Diller Material 3 Depth (T TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION C1 DESTRUCTION C1 INo septic system permitted if public sower is � available within 200 feet.) 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. O Typo/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Lino LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS if Depth Size Number SUMPS ll Distance to naresu- Well Foundation Property Lino DISPOSAL PONOS O 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 Homo 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:"1 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 mus ad f ag req 'red Inspections. Complete drawing on reverse side. DD Signed Title:C0-,05-UL;-4 ^JT Date:SE21. 2& IC6 3 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: 1 j^C✓y4t+ Applicant - Return all coy a tot BAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES n I 445 N SAN JOAQUIN, P O BOX 2009. STOCKTON. CA 95201 3�" / INF( AMOUNT DU AMOUNT REMITTED H RECEIVED BY DATE PERMIT'NO. . IN 13 4 MeV.1/.4! EK 14-25