FIELD DOCUMENTS FILE 1 - Laserfiche WebLink

Home Browse Search

- ` APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH ogRVIC ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN , PHONE ( 209 ) 468 -3420 NOV 1 01993 P O BOX 2009 , STOCKTON , CA 95201 EE PERMIT EXPIRES 1 YEAR FROM DATE ISSUENND 'VIRONMENTALI-IEAMf ( Complete in Triplicate ) PERMWSERVICES Application In 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 1662 and the Rules and Regulations of San Joaquin County Public H.,ealthl Services . f I Job Address I VY7 Jam ' r _il(t_t ( 10 City =74,1uL, k.-i'ZTr\ Lot Si ze/Acreage _ Owner's Name ' 1 1� to Hodac-1 � 1 nilll1P Address ? L /fir V I ` Phone Contractor �,1�'JC?f (p1 & 1 (1 11Y ddress U I)�?�_,+�.r 4-' License No. 50 C Phone TYPE OF WELL / PUMP : NEW WELL ❑ WELL REPLACEMENT L1 DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 0_ 1_STANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/ SUMPS II INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I 1 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f 1 Domatllc/ Pdveta ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I Public fa Other fl Delta Depth of Grout Seal '4 Type of Grout "CA h . ONO I I hri0ation _ Approx . Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H . P . State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth N 1 Depth Tiller Material i Depth TYPE OF SEPTIC WORK : NEW INSTALLATION I I REPAIR /ADDITION I I DESTRUCTION I I ( No septic system permitted if public wwer is available within 200 last. ) Installation will serve: Residence _ Commercial _ Other Number of living units _ Number of bedrooms Charseter of soli to a depth of 3 fat: Water table depth SEPTIC TANK ❑ Type/ Mfg Capacity. No. Compartments , PKG . TREATMENT PLT. ❑ Method of Disposal — Distance to neuat: Well Foundation Property Lina LEACHING LINE ❑ No. Ii Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Sire Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate 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 1 employ any parson in such tanner as to become subject to workman's compensation laws of California . " Contractor's hiring or sub-controcting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shell employ persons subject to workman's companion lion Ism of California . " The spMicen .rp Coll for NI raq irpd Inspsclions. Complete drawing on /reverse side. ) l 1. Slged K d / Title: 6 rt kva .� / Date: / _ Z/– f FOR DEPARTMENT USE ONLY Application Accepted by 7 7 DateIII Pit or Grout Inspection by _ Date ��-/0�7 ` / Final �I,{ns�precti n by Data o �( � Additional Comments M I / PA4 J s"� Applicant - Return all copies to : San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin , P .0 Box 2009 , Stkn , CA 95201LULr , FEE NFO AMOUNT DUE AMOUNT REMITTED 17ASH R CEIVED BY DATE PERMIT' N0. (c� . tvo � . az� IzB> 1- V3 I M14