FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

` . APPLICATION FOR PERMIT J SAN JOA©UIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 B. HAZBLTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 (Complete in Triplicate) r44- rql-tz-o Application is hereby wade to San Joaquin County for a permit to construct and/or instau the work herein described. This syplicatioa is aade in ca pl2ance vith San Joaquin County Ordinance 80. 549 and 1862 and the Mules and Regulations of San Joaquin county Public Health Services. Job Add ase 204 East Lodi AygnUa __ City T. i Lot Size/Acreage - 32151 Owrnr's Nwy Address Phone 209 - i �-- Po•IMW3 34, v>V6i-,i y4 Contractor Address License No. Phone 2f)9-956-014 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION c; Out of Service well O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well IX DISTANCE TO NEAREST: SEPTIC TANK n/a SEWER LINES 50 ft _ DISPOSAL FLU. PROP. LINE 4 5 FOUNDATION 15 --t AGRICULTURE WELL OTHER WELL 350 PITS/SUMPS mj-a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION_S n Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation S" _. Die. of Well Casing " ❑ 00mastk/Private 0 Gr" Pack ❑ Tracy Type of Casing Specifications I'I Public n Other n Datta Depth of Grout Seal 5.51 Type of Grout Pin r-t-I and I I Irrigation _Approx. Depth IX Eastern Surface Seal Installed by Repair Work Done U Type of Pu nV H.P. Stats Work Done WW Desmmion ❑ WON Diameter 8 u 8ealin6 Material i Depth Monitoring Depth 701 lillOr Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRfA001TION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will terve: Raidatcs— Commercial_ Other Number of wing tawts: Number of bedrooms ChwwW of soli to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT,❑ Method of Ditpotal Distance to nearest: WON Foundation Property Line LEACHING LINE 0 No. E Length of Una Total length/size FILTER BED D Distance to nearest: Well Foundation Property Line t^� SEEPAGE PITS I I Depth Sire Number SUMPS Ll Distance to nearest: WON Foundation Property Line c DISPOSAL PONDS 0 1 hereby certify that I have prepared this spiphestion and that the work will be done in accordance with San Joaquin county ordinances, state laws, and tufa and regulations of the San Joatluin County Home owner or kerwed agaht's sigrau"certifies the following: "I certify that in the performance of the work for which this permit is issued. I shelf not Ornploy any person in such manner as to become subject to workman's compensation laws of Califomia."Contractor's hiring or sub•wntracdng signature citifies the following:"I certly that in the pafonnahce of the work for which this permit is issued.1 shah employ persons subject to workman's compensa- tion Is"of C111100rnis." The appkent lust 90 for all Complete drawing on reveres tide. S1I/„ igned x Title: Date. 3 FOR DEPAATM NT USE NLY Apokedon Acwtod by Dat* 9 R' , p Ana �h Pit or Grout Inspectoeh by Dsa�2U�� F lrapection �^a"� ate b q2— kk- Additional CommartW ✓ MW� r rhled 1 / AMU"" - lloturta all Dopier to: Ben Joaquin County Rtblic Health c2titt �i,. lrn� tui i7 �f�i- Services, Htavirocisental Health POrnit/Services 1 (J 16M S. Has lton Ave., P 0 Bots 2009, Stockton, CA 95201 r ftsASAOUNT DW AMOUNT REMITTED Iwo RECEIVED RECEIVED fly DATE PERIrdT't+10. . t tlr�IRa1►.t, t� 8R. Do CIT. � -301 T 3. 112 q.7• ds�� EN 767a