FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTh SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 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 Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address I r•,."r. +:gt.. ... r 1 '; ! .F.. City l ! Lot Size/Acreage ....^.�:... t.: C.G:.. ...... •�' �. Int Address .fir Owner's Name t � . ADhone r`F - t'= Contractor . ,,.�': .�-s. .:.�.a.�' ° Address 1 'T... - c��L.f License No.�:v' �� Phone s TYPE OF WELL/PUMP: NEW WELL :D WELL REPLACEMENT 7 DESTRUCTION 570ut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C Monitoring Well p DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES a DISPOSAL FLO. PROP. LINE Lr. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial 0 Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications is Public (1 Other [-1 Delta Depth of Grout Seal Type of Grout 11 Iraigatton —_ Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done Ll Type of Pump H,P State Work Done _ Well Destruction N� Well Diameter Sealing Material t. Depth ti .13 •, -r- k 2'i L - C Filler Material & Depth fl -, `rpt { ,�` - 7r 1 .--}r Depth - -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITiON I I DESTRUCTION I I fNo septic system permitted if public hewer is available within 200 feet.) installation will serve: Residence_ Commercial _ Other ` Number of living units: Number of bedroom Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK fl Type/fvlfgCaps ty No. Compartments PKG. TREATMENT PLT. Cl _ Method of Di osal Distance to nearer . ell Foundation Property Line _____�•- i LEACHING LINE Ll No. & Length of lines Totaklengibl'x e FILTER BED ❑ Distance to nearest: el! Foundatit)tt �Flr.__op�'rty Line --rte' - SEEPAGE PITS 1l Depth Size_ NumbarI SUMPS LI Distance to nearest: W04 =. :. Foundatr rid` PrOlZerty Line DISPOSAL PONDS ❑ t hereby certify that I have prepared this application an that the work v6l be done fn,.&�vrdance 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 coni y that In'tthe performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to work man'�,96'7pprititition I"of California." Contractor's hiring or sub-contracting signature certifies the following: $certify that in the performance of the work fOrAhidh this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. r . Signed X .... .;:., :. t_.. r x' ,,. tje.c.: �^. ;`..-. .a - z..,fI f Date- r .. r <. U . •:,,.c•�:�:�- = FOR DEPARTMENT USE ONLY Application Accepted by •y .....� c' �_ Z_...';: "_ Date ... f r ........ Area Pit or Grout Inspection by Date r'mal Inspection by Date Additional Comments: Applicant - Return all copies ta: San Joaquin County Public Health Services Environmental liealth Permit/Services 445 N San Joaquin, P 0 Sax 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH E 13-24 IAEV. H EH 14-26