FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

x A PPL I C-1'p T-()N �r.� SAN JOAQUIN COUNTY PUBLIC HEALT11 SERVICES � ENVIRONMENTAL HEALTH DIVISION 445NSAN jo2009 ,IN POSTOCgTON(PHONE20A)468 95201�20 PERMIT EXPIRES i YEARFROM DATE ISSUED (Complete in Triplicate) k vorX in cgLde toSinJoaquin county ce with San Joaquinfor a permit mrdlnancenNoru5�9aando1g62 and ther install applicationRules and eRegulations dof San s Application is hereby application is mad Imp Joaquin County Public Health Services. A:Z(4 wP � � City l�U�1 Lot Size/Acreage ' Job Address 7GQt y rr tt L�c3 �71�1 3�i j Phone 1 Owner's Name Address CC�� nto,nG 'N'..(1104-9+ U4 1 !� QZ�1 -` 133 ii 2 Q,r Jlrt License No. f'a 104-9 Pfion f' SIeTr0. ExP117t1�t1Addres5. O Z t Contractor —--_— DESTRUCTION CI Out.of Service Well ❑ I TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT C1' Motlitoring Well SYSTEM REPAIR D OTHER :3 "sol borin�s PUMP INSTALLATION O J � p �. DISPOSAL FLD: PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -�_- — FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing N Cl industrial ❑ Open Bottom ❑ Manteca Dia. of We'll Excavation NA Specifications- NP` f.l DomesticlPrivate 0 Gravel Pack ❑ Tracy Type of Casing_ rl Delta Depth of Grout Seal PA A Type of Grout ° I'1 Public (a Other N A I i lrrivati°n _.Approx, Depth I I Eastern Surface Seal Installed by H.P. State - Repair Work Done ❑ Type of Pump Work one Well Destruction LD Well Diameter Sealing Materiallti Depth Depth Filler Material Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I i INo septic 'system permitted 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: Water table depth • i SEPTIC TANK 0 Type/Mfg Capacity No. Compartments' PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Fl No. & Length of lines Total length/size FILTER SED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well 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 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 of 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 apptcant mu calf for all quir inspecti s. Complete drawing on reverse side. + Signed X 'Ti,,,, �tt�U �l��rI S�S Date: 9111 FOR DEPARTMENT USE ONLY Application Accepted by Date Area CJ Pit or Grout Inspection by Date F no Inspection by Date Additional Comments: L ✓" Applicant - Return all copies to: San Joaquin County Public Hea h Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFOAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE "PERMIT'NO. • EH 53.24 IREV.i i n 51 -1 CH 14.26 ;'