FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

:APPLICATION SAY JOAQUIN COUNTY PUBLIC HEALTH SERVICES L-INVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE ISSUED ,Comnierne in 'I'riaiic e / Application is nereby made to San .ioaquin County fcr a permit tt construct anaior install tie varx herein oescri7ed. This application is mace in compliance with San J.;aquin Cour ty Ordinance No. ara 1Co2 and the Kuies and Regulations of San Joaquin Ccunty Public Health Services. 00 Address � L y � W t �_ze;A_reale Owner s Name P t1 L; ' "r Address { _ _ _ Phone', ;Cnlrador )s �adress_ ' -,,2 _ense No._ Phone TYPE OF WELL;PUMP NEW WELL WELL REPLACEMENT DESTRUCTION t.., out of Service well ❑ i PUMP INSTALLATION G SYSTEM REPAIR 7 THER monitoring well r� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS :NTENDEfl USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF3CATIONS f industrial Open Bottom Manteca Dia of Well Excavation . Dia. of Well Casing Domesticl Privare Gravel Pack• Tracy hype of Casing_ Specifications ry Public Delta c.)r: i Depth of Grout Seal. Type of Grout:::;. .xr.: €rrigalton ., Approx. Depth _r -Ea5rern Surface Seal installed by Repair Work Done Type of Pump H P. State Work Done Well Destruction E Well Diameter Sealing Material & Depth r Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR,ADDITION i DESTRUCTION 1 i INo septic system oarmittied 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: Willtef table depth SEPTIC TANK ❑ Type/Mfg Cagacrty No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of linea Total length/size FILTER BED [__1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS If Depth Sire Number SUMPS LI Distance to nearest: Well _ Foundation Property Line DISPOSAL PONDS I hereby certify that I have prepared this apphCavon 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 ficsnsed agent's signature candles 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 persons subject to workman's compensa- tion laws of California." The applicant piAll...call for all required inspections. Complete drawing 09 re'lerse ... ... ,Wr JipS) g Signed x � 'w.... 1..� �. ✓ ` " �G'/ ^^f� , Title: � '�.y'�:�,..y� jG't',<. � -�.,+'..�1 Date- i FOR DEPARTMENT USE ONLY Application Accepted by -ter "=c-- Date - Area P'it or Grout Inspection by Date Final Inspection by Date Additional Comments: 1ppli,.-ant - iieturn all �:opies to: San Joaquin County Public Health Services Environmental Health Permit/Services ri 495 N San Joaquin, P 0 Box 2009, Stkn, c: 95201 NFO FEE AMOUNT DDE I AMOUNT REMITTED CASH RECEEVEp By GATE PERMIT NO. EH 1321(REV i n}t! ] - EH 14.20 l i