FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

• SAN '7AQUIN COUNTY PUBLIC HEALTH - 'tVICEsS ENVIRONMENTAL HEALTH DIVIS_ PAYMENT 1601 E. HAZELTON AVE. , PHONE (209)468-3420 RECEIVED P O BOX 2009, STOCKTON, CA 95201 SEP 0 3 1931 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAS! JOAQUIN CC"�,!Tv (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or installs work 7ierein 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. /� Job Address 41S N . I�t•n �r,w �� City Mlp' TLot Size!Acreage 0,5— Q(�Q T ��,e 2? (A 9��3 Owner's Name g t M�,ddress �J GL 0Y! Phone hr+eSSaar 2q [+,i 41 �nvirOnrnent�r� C,0mVI}Pt'tfAddress t00 Shoreline Hw Svlte ��I� YA,I I Co,C� I Contractor License No. �7��0 � Phone B 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ $0 PDI` &_6 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE D D�epne el n FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ff1P1O� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d-etec:tJ Oil n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r eq I I Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public I:I Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material Z Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size `• FILTER BED El Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI 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, 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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature v 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 must call for ah required inspections. Complete drawing on reverse side. ' Signed X 66_VI it Ia .c'��S Title: !. ' I Lill l W l�/�� Date: - - D 1(LW°4 FOR DEPARTMENT USE ONLY App cation Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 1t p Applicant — Return all copies to: San Joaquin County Public Health �i�)t h� O 1.0 0 Services, Environmental Health Permit/Services i7iJ 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 3 h r Mtt\ 0000 INFO CASH FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. • EH T3-24(REV 1/"5) /)�//)06 EH ib23214-28G((fiVX /�