FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

" APPL•ICATION t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Q ENVIRONMENTAL HEALTH DIVISION 1 445 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 construct and/or install the work herein described. This application is made in com�liance with San Joaquin County ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 3glS- 71Z/-{CY iSGULOVAM City -MAC, Lot Size/Acreage o.S Owner's Name AR-co P/La„AC7S• . Co. Address P.O. avv 5811 CA 44S44 Phone `{151571- Z4 3%( Contractor &JAYat MLUJG CO. Address P.o. UWc _1U. L'Acow, CA gSGY$ License No. 3-75-147 Phone %/4w5-74'f5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Sr '°t' " t3°BgSI DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE /Or FOUNDATION I$' AGRICULTURE WELL OTHER WELL L_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �3 k ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation � Dia. of Well Casing C] Domestic/Private ❑ Gravel Pack7 CKTracy Type of Casing_ Specifications Il Public ;K Other-[totuwlG Cl Delta Depth of Grout Seal f S' Type of Grout CL"MG'Aor I I Irrigation 1?.Approx. Depth l I Eastern Surface Saul installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing l+laterial i Depth Depth Filler Material i 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.l ..installation will serve: Residence— Commercial____ Other - I Ntimber of living units: Numbef of bedrooms Character of coil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT.❑ Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of linea Total length/site FILTER BED ❑ Distance to nearest. Well Foundation Property Line ' I SEEPAGE PITS 11 Depth Sue Number SUMPS It Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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, 1 shall not employ any person in such manner as to become subject to workman's compensation taws of California."Contractors 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." j The applicant must call for oil required inspections. Complete drawing on reverse side. Signed x �� ✓/ Title: /°.� t-Sr 660106rs Date: S/�t7,43 ` FOR DEPARTMENT USE ONLY V��Application Accepted by Date U Area L Pit or Grout Inspection by Date -`3 Final:asper•tion by .. �" `�l ^^ Date 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 � � K INFO FEE AMOUNT DUE AMOUNT REMITTED CASH K 9 RECEIVED By DATE I PERMIT-PEO. . E+; 1 3.241REV.,ix5, a12 ] U 11V EH 114.26