FIELD DOCUMENTS_FILE 1 - Laserfiche WebLink

Home Browse Search

\ . APPLICATION FOR PERMIT • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION op 1601 E. HAZELTON 200 AVE. , PHONE (2095201 420 P 0 BOR 2009, STOCgTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made,ta San Joaquin County for a permit to construct and/or install the work herein 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. t " /1 G�.�6--f pac/-/C 1"VQ City �r-k4 ,,` Lot Size/Acreage ' 3oy Job Address U,toCA-( Ca, Address �o. /�oX S/sS—da , .,r CA 510 a9313� Phone Owner's Name Contractor Weskx Address;d se No. 5 /9S Phone(qtz tz13 It Well TYPE OF WELL/PUMP: NEW WEST ELL;& WELL REPLACEMENT ❑ DRUCTION ❑ Out of service e Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK N SEWER LINES DISPOSAL FLD. PROP. LINE — FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �/ Ht ❑ ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /t7•LS yA' Dia. of Well Casing T Cl Domestic/Private Gravel Pack ❑ Tracy Type of Casing sel� '{'d p✓G Specifications _ / —�-- I'I Public V t I.1 Other fl Delta Depth of Grout Seal /O��i� Type of Grout ��a//'' -Ylwr7ra.Es sGw I Irrigation �v"W —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ r Sealing Material i Depth B-2 � 0 Well Destruction ❑ Well Diametter"'LL 'A. 7-0 _<, Depth ''7TFiller Material i Depth ea r�d TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (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 Water table depth Character of soil to a depth of 3 feet: . Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa. tion laws of California." The applic ust call for al .egrBO inspections. Complete drawing on reverse side. ? JvJate: /fZ Signed _ / Title: b� �i•-r FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date �� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health /J ,q• �(` Services, Environmental Health Permit/Services 1601 E. Hazelton Ave.. P 0 Box 20 tockton, CA 95201 FEEcK EIVED By DATE n_=_6 Willi AMOUNT REMITTED NFOcEN 173x IREV.rrsal �� /J EH".LLm