FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION SAN J04AIUIN COUNTY PUBLIC HEALTH SARICES ENVIRONMENTAL HEALTH DIVISION' 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOA 2009, STOCKTON, CA 952, L PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application in hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application in 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 ItI��1�? )�Yo ��i1L�1- iX .__,_-.-_ Ci:ys k�,m_ Lot Size/Acreage Owner's Name �Q✓W1es VLJ _c_-_ Addrass7 Zts!rs�l"u Phone ?�i Contractor y Address � �•k..rc._ � License No, Phone (0 TYPE OF WELL/ UMP, NEW WELL 0 WELL REPLACEMENT fl DESTRUCTION iC-1 out of Service Well D PUMP INSTALLATION `` SYSTEM R R ❑ OTHE Monitoring We 1 ❑ DISTANCE TO NEAREST: SEPTIC TANK t SEWER LINES � CS DISPOSAL FL_ a TPROP. LINE��Y.:p FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private D Gravel Pack L-1 Tracy Type of Casing__- 7 Specifications I'l Public ,)r�o(lLhar ^telta Depth of Grout Seat Type of Grout + I (rrillahon , y[ ppfox. Depth I I Eastern Surface Seal Installed by (vrf Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction Q Well Diameter Sealing Material i Depth Depth Filler Material L Depth 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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. 8 Length of lines _ Total length/size FILTER BED n Distance to nearest: Well r Foundation Property Line SEEPAGE PITS 11 Depth Number SUMPS LI Distance to nearest: ell _ Foundation Property Line DISPOSAL PONDS CI I hereby certify that I have prepared this application and that the work will be dans 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, 1 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 must call fol all qui ry inspections. Complete drawing on reverse sid . Signed X Title: y ��-Z �J Date: FOR DEPARTMENT USE ONLY Application Accepted by _ _ Date �Z, 1 Area Pit or Grout Inspection by Date Final Inspection by Data-4—Z7-1 3 Additional Comments: Appllcnnt - Return all copies to: San Jongu.in County Public Health Services nL 9 So S� Environmental Health Permit/Services 445 N San Joaquin, P O [lox 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK A(;ASH RECEIVED BY DATE PfRM1T'NO. EH 1324MEV,i/n51 do 1 — EN 14-M )0 )1 b(Pl