FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

,, APPLICATION SAN WAQUIN COUNTY PUBLIC HEALTH QRVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 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 conatruct 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. - City r�i,ot Size/Acreage Job Address Owner's Name '^� Address ��, M�5S1�- Phone7 '17 Contractor V �COcj t�,) dress �.J O- gest _3_3 �a l icense Na.-7/0072 Phone Ot TYPE OF WELL/PUMP: NEW WeLL ❑ WELL REPLACEMENT Cl DESTRUCTION V Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER CI Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK /D0 SEWER LINES N'41 DISPOSAL FLD. �� PROP. LINEo �� FOUNDATION, 5--�1 AGRICULTURE WELL J/r¢-r=OTHER WELL-1!Lt— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial Q Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Wel! Casing _ Cl Domestic)Private ❑ Gravel Pack 0 Tracy Type of Casing_ �V� - _ Specifications I'I Public Cl Other fZ Delta Depth of Grout Seal �" + Type of Grout IRc1JDIAI t- I I Inigauon _Approx, Depth I 1 Eastern Surface Saul installed by '� Repair Work Done 0 Type of Pump H.P. State`Work q Sealing Material 3 Depth Well Destruction Well Diametery -- Depth _ ft Filler Materiel i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION r I REPAIRIADOITION t I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 lea;.) Installation will serve: Residence — Commercial — Other Number of living uniis: 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size �r.� FILTER BED 0 Distance to nearest: Weil Foundation Property Line COD SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 or sub-contracting signature certifies the following: "I certify that in the performance of the work tar which this permit is issued, I shall employ persons subject to workman's compense- tion laws of California." The applicant m t caq for it quired inspe, ons. Complete drawing on reverse side. Signed Title: Date: L FOR DEPARTMENT USE NLY Application Accepted by Date Area �'� Pit or Grout Inspection by y/ 'tM tri Date S✓ 3 Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P o Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT NO. n 7 J INFO �( (] r/C V 1 1791? 1- EH 13-241rrEV.i/n5� 6V,C_)� �O,t�t� O ar/ �"L 5ROO / �.�`L'rd' EM 14.2a t