FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONJMTAL HEALTH DIVISION � 445 N SAN JOAQUIN, PHONE (209)468-3420 J P O BOX 2009, STOCKTON, CA 95201 T E%P R S YTs FR !d DATE I� S17,Pq -:r ! (COmPlete in Triplicate) APPlicatlon is hereby made to Sea T f oaquin County for a permit to construct and/or install the work herein descsibtia . This application is made in cot'liance frith San Joaquin County Ordinance No. 549"and 1862 and the Rules and Regulations of San i Joaquin County Public Health Services. I p Job Address �,� f•% �I,'� 1- P ^J,�}�! City f !i�;'�it Lot Size/Acreage r 4� n I� F Owner's Name Address L= �CF',� c f� L � hOAI V L-ft Phone�,^'ji� ! �contracto �� C. kT�t l� Address l L�-f I, License e Na. �3r 4Fqr79 Phone oJrJ�cl:;', TYPE 1 OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑I i[DESTAUCTION ❑ Out of Service Well ❑ PUMP INSTALLATiSYSTEM REPAIR Elp OTHER C) Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK WA SEWER LINES r DISPOSAL FLD. PROP. LINE r'I FOUNDATION ^` AGRICULTURE WELL h•+ OTHER WELL l PITS/SUMPS-1i i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r Cl Industrial .9 ❑ Open Bono m ❑ Manteca Dia. of Well Excavation�7_".i —T Dia. of Well Casing ! 1- �) Domestic/Private Gravel Pack C3 Tracy Type of Casing M- 11 Specifications? HF.g`51-!E 40 t Il Public n Other f-1 Delta Depth of Grout Seat �� .` Type of Grout-50is O/I' rk + I I Irrigation —Approx. Depth I I Eastern Surface Seat Installed by {{ Repair Work Done C7 Type ype of Pump H.P. State Work Done_ i Well Destruction ❑ well Diameter Sealing Material i Depth it .k N N(;OPrs6 &.-J, Depth tiller Material i Depth if 11 E TYPE OF SEPTIC WORK; NEW INSTALLATION ( I REPAIR/AODtTION I I DESTRUCTION I I INo septic system permitted if public sower is available within 200 fest.) Installation soil)serve: Residents_ __ Commercial_ Other Number of living units: Number of bedrooms r Character of will to•depth of 3 feet: Water table depth SEPTIC TANK 13Type/Mfq Capacity I i�N No. Compartments p PKG. TREATMENT PLT.❑ Method of Disposal t ' Distance to nearest: Weil Foundation Property Line IE �p � LEACHING LINE ❑ No. ik Length of lines Total tengih/size FILTER SED ❑ Distance to nearest: Weil Foundation IJ Property Line SEEPAGE } EEP GE PITS I I Depth Size Number .I1 SUMPS LI Distance to nearest: Well Foundation i# Pf1openy Lina DISPOSAL PONDS ❑ i� r 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 k 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 tha work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature p csrtifin the following:"I certify that in the performance of the work for which this permit is issuetl, I shalli�omploy persons subject to workman's compenss- f tion+laws of California." The applicant t call r of equasd inspections. Complete drawing on reverse side. f Signed Title: n1t1f I Jr f,EA. I l/ �>�:A Date: �: I.1` OPARTMENT USE ONLY , # I f zz F App)ication Accepted by Date 1�J2, 3 Pit or Grout Inspection lon by � Final Inspection I by C Daa Z Additional Comments: i i Applicant - Return all copies to: Baa Joaquin County Public Health Services Environmental Health Permit/Services it 445 H San Joaquin, P O .Box 2009, Stkn, C,� 95201 FEE .i INFO AMOUNT DUE AMOUNT REMITTED CK CASH AECENED BY OATS PEAMIT iVO. o EM 13-24(REV.1/1161ZzA9Z] EM t4-a3 2^+ Y