FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

�- SAN .UIN COUNTS`FdBLIC HEALTH ,ICES �VIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 �1 S '�"-� " L P O BOX 2009, STOCKTON, CA 95201 PERMIT MIRES 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. C C ^� Job Address +! �t% �' `��[S��Lic-�� r 1 . City -DQ k"LSN Lot Size/Acreage 7 Owner's Name Ry T`1 DF ��Z 111�L`l� Address -D3 J L Lh"N1'kf�i - Phone -Al- Contract(r604LIL- - _VL %-I:JZ- Address ,3A2.S tyy'tt-'!- `y` License No. 7C 4P 7-4 1 Phone�r e►i-V L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT i1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATAIO.N'^O SYSTEM REPAIR ❑ ,�rOTHER ❑ Monitoring Well RL DISTANCE TO NEAREST: SEPTIC TANK �, ��,.[inA SEWER LINES 7 3� , DISPOSAL FLD. TI-4 PROP. LINE avr FOUNDATION PV.� AGRICULTURE WELLAI fA OTHER WELL-1.;.64- PITS/SUMPS A-U)-4' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z n Industrial ❑ Open Bottom ❑ Manteca Dia.'of Well Excavation F, Dia. of Well Casing f i`Oomestic/Private id Gravel Pack ❑ Tracy Typb of Casing_ Pv-L Specifications I'l Public f'1 Other n Delta Depth of Gfout Seal J' Type of Grout 1 I Irrigation ,Approx. Depth I I Eastern Surface Seal Installed by %vlL %w Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Z Sealing Material i Depth Depth L5 ' tiller Material i Depth i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION 1 1 INo septic system permitted if public sawer is available within 200 feet.! Installation will serve: Residence _ Commercial_ Other Number of living units: Number of bedrooms Character of SOA to •depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 candies the following: 1 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 subcontracting signature certifies the following: -I c*nity 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 sa` all fC 1 req ' ed inspections. Complete drawing on *verse side. Signed - ft�L4�S1 X Title: � Oats: C. 1 ql _ OR DEPARTMENT USE ONLY c� Application Acc*pt*d by Date a Pit or Grout Inspection by/�/ ` Date -3-2 Final Inspection b Data �Z Additional Comments: "L z 3 Applicant - Return all copies to: San Joaquin County Public Health Services 61 1 ED V Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 cur iFEEO AMOUNT DUE AMOUNT REMITTED CASHCK 11 RECEIVED BY DATE PERMIT NO. 27,0/ I • EN 13-24IREV.��■ei g C.J � / [N 162a f