FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

r 'Y APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC- HEALTH SERVICES . ENVIRONMENTAL HEALTH DIVISION -i 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 - -PERMIT EXPIRES 1 YEAR FRQ-M DATE ISSUED (Complete in Triplicate) ;� F 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 Ro.,,549 and 1862 and the Rules and Regulations of San Joaquin County PublicHealth Services. Job Address ��V ' �� ' S t City<5 ALot Size/Acreage Owner's Named^ G' cZ7' `'`' Address vD� '�Q�`� �` `�O�Phon - Contractar-=;K: P�'7 Address ar/)M1I'1r� �A_ 'gy5 3 License No. /37�/ZZ_Phone 2-T-2'9 Z- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ - PUMP INSTALLATION ❑ SYSTEM REPAIR O /fCT(fd T ER Yt3 Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK ` �� SEWER LINES G SO-F-f DISPOSAL FLD. PROP. LINE /p f'r FOUNDATION AGRICULTURE WELL 71170 #OTHER WELL 7 Sa z�PITS/SUMPS >42'> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial _ . ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing • d X Domestic nva ❑ Gravel Pack ❑ Tracy Type of Casing -P(/C- Specifications i'1 Public W Other VIdtaSe fl Delta . Depth of Grout Seal S Type o1 Grout-R-0 -•{lAftale4 f I I Irrigation 1- .Approx. Depth I I Eastern Surface Seal Installed by a Y► __ Repair Work Done L7 Type of Pump A/4 H.P. State Work e_ Well Destruction ❑ Well Diameter 2 y Sealing Material i Depth CC�'tti.3Donbr�7b��t; O . Depth D biller Material i Depth.' ' IZWe� S A,• SeP�- 0. 46 S. • TYPE OF SEPTIC WOR JW INSTALLATION 11- REPAIR/ADDITION 4,3--DESTRUCTION 14-INo septic system permitted if public sewer is /7 available within 200 feet.) w 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. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size y '' FILTER BED N/ ❑ Distance to nearest: Well k Foundation, _ Property Line ~j GA SEEPAGE PITS�f/ I 1 Depth r5iie ' "* Number f• �� < , SUMPS _LI ". . , . �._ . Distance to neares-t: 'Well` � Foundatioo n ,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 3 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 compenss- tion laws of California." The applicant must call for all required inspections. Complete drawing OILZAVerse side. Signed Title: -/!/M �a!/L- Date: r FOR DEPARTMENT USE ONLY U a ' Application Accepted by Date `�� Area f Pit or Grout Inspection by Date Final,lnspection by Date Additional Comments: COS �f�1LV OZLZ1YYtOcnfi` I/Vl� � � � � Applicant - Return all copies to: San Joaquin County Public Health .� - r 0. Services, Environmental Health Permit/Services 1601 E. Haselton Ave., P 10. ) Box 2009, Stockton: CA 952oi FEE CK INFO AMOUNT DUE li� UNT REMITTED CASH RECEIVED BV pATE PERMIT'NO. - F' A ' EH1��pIREv.rixsl � t`�°„ ,>(P2 '.'