FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION D SAN 70AQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAOUIN,PHONE(209)469-3420 S E P 0 7 1994 P O BOX 388,STOCKTON,CA 95201-0388 PERMIT MIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH .11-(complete in Triplicate) PERMIT/SERVICES Application is hereby made to San Joaquin County for a permit to'6onstruci and/or install the work herein described.This application is made in compliance with San r Joaquin County Development Title Section 9-1110.3 andlSection 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. f Job Address _ 4 3725 WAST WZ6(F2 AVE- City '5rCCKTaAJ Lot Size/Acreage i Owner's NameG�T�LZys D£1l�Z�Ci tt�►Address 2,01 MIS5l0lU 57 -41bth FPhone 44!9 ;K4 PrrV �izr�is t1 C f S CO f a5 --MAA ConIfacI.ori�FCr� (� oSrkn90lr - Address 43Z 41- CE0r4CS SOtAA;A FSz� � 9Z,� qlb_ 3Z3 rc'ense Na. Phone ' TYPE Of WELL/PUMP: NEW WELL ❑ i WELL REPLACEMENT P DESTRUCTION C1Out of Service Well ❑ing PUMP INSTALLATION G SYSTEM REPAIR. ❑ OTHER Q,:�ilIiv Well CJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom fl[D Manteca Dia. of Well Excavation 2. 11V4f E5 Dia. of Well Casing 11 {1 Domestic/Private ❑ Gravel Pack 0 Tracy. Type of Casing- Specifications i`l Public is Other n Delta Depth of Grout Seal EN71t2� SLE Type of Grout i I I Irrigation _Approx. depth III Eastern Surface Seal Installed by 7MG- t39rrtsr0'Ulrrc— 14'r2tz`2 2-- h } Repair Work Done U Type of Pump H,P, State Work Done �I Well Destruction ❑ Well Diameter Sealing Materiel i Depth �fU irdAai 1'�—�,atsTfrL��IoL� } I Depth_ I� � Filler Material & Depth �J r TYPE OF SEPTIC WORK: NEW INSTALLATION �. I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 4 available within 200 feel.? Installation will serve: Residence CommeLial 1 Other n f, Number of living units: Number of bedrooms j ` Character of soil to a depth of 3 feet: 11 Water table depth SEPTIC TANK ❑ Type/Mfg yI l Capacity No. Compartments PKG. TREATMENT PLT. ❑ ? Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of linesi fl Total length/sire FILTER BED n Distance to nearest: i> Well Foundation Property Line SEEPAGE PITS I I Depth Si:e Number SUMPS LI Distance to nearest:: Wet 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 �! 0,I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work lot 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: "I certify that in the performance of ttie work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." !' 31 _ The applicant mus r all required inspectiona. Completa drawing on reverse side. SE'Z I:frrFi04 -C> FIGL �S Signed t Title: `� rZ� Date: I--Z 9 -- FOR DEPARTMENT USE ONLY i Application Accepted by ' Date l` Area `� O Pit or Grout Inspection by it Date final Inspection by Date Additional Comments �I Applicant: - Return all copies to; SanJoaquir►County Public Health Services Carm ME t Environmental Health Permit/Services r5 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 Q�a FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED 8Y DATE PERMIT N0. INFO ��(y (/��,, /r d r cn ` EH 13.24(REV.S/N 51 V 1. �U i 1 •�aF+� ! `�+' L 7 `^� 2� i' EH 14.16 _ �