FIELD DOCUMENTS_CASE 1 - Laserfiche WebLink

Home Browse Search

APPLICATION AllL� / ON SAN JOAQUIN COUNTY PUBLIC HEALTHSERVICES SCI I ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE(209)469-3420 P 0 BOX 388,STOCKTON, CA 95201-0388 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to 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 Development Title Section 9-1110.3 and Section 9.1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address -�7� � City j lb t-17A Lot Size/Acreage Owner's Name 'Sir\'v�. �..-c.te. qdd ass // S,*� Phone Contractor � _ Address _ �_ ] , Licens4P??s 10(7 Phone �i � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Wellj DISTANCE TO NEAREST: SEPTIC, TANK IVIV SEWER LINES 3cr0 -P-7 _ DISPOO*L FLO. iYv1' PROP. LINE Y,_-f 7 FOUNDATIONL2 +1_AGRICULTURE WELL A/rL OTHER WELL iY# PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M Industrial O Open Bottom ❑ Manteca Dis. of Wall Excavation Dia. or Well Casing 611 Oomestic/Private ❑ Gravel Pack O Tracy Type of Casing__._ n� I Specifications 1'1 Public 1-1 Other n Delta Depth of Grout Seal 1 F7` l.�".a/'+ev, ! Type of Grout �`Y I I Irtlgation —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 r, Sealing Material L Depth F1uv�l.a-,n, Depth Filler Material L Depth 17 / TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADOITION 1 I DESTRUCTION I I (No septic system permitted it public sewer is available within 2001est.1 r� Installation will serve: Residence _ Commercial _ Other �+1 Number of living unite _ Number of bedrooms Character of wil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE O No. 6 Length of lines _ Total length/size FILTER BED ❑ Distance to nearest Well - Foundation ____ Property Line SEEPAGE PITS 11 Depth Size _.__ Number SUMPS U Distance to nearest: Well __ Foundation _, Property Lina 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 licensad agent's signature ceniGes the following: "I certify that in the performance of the work for which this permit is issued, 1 shell not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub•conuacting signature certifies ilia following: "1 certify that in the performance of the work for which this permit is issued. 1 shall s�ploy persons subject to workman's compenas tion laws of California." The applicant must call fo 1 r uired inspections. Complete drawing on reverse side. 1i 4y r� 4J� -�iY Signed X' l �'^ Title: GccX.M:., b� lalLS Dau: FOR DEPARTMENT USE ONLY . nz r// !J Application Accepted by ��+'*�^^'" -` Date _r �1T/-7/�/��,yA(nJ.a L Pit or Grout Inspection by Date Find Impaction by �"" `" DeiTT n' f Additional Comments: t9l : /7- 630 - I Applicant - Return all copies to: San Joaquin County Public HealthServices Environmental Health PermiuServices 445 N San Joaquin,P.O.Boz 388,Stockton,CA 95201-0388 FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. n ♦C,j API, + '/ �L� 41