FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

I = APPLICATION SAN AQUIN COUNTY PUBLIC HEALTH; RVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE {209}468-3420 P 0 BOX 2009, STOCKTON,.jJ CA 9;5201 ' PERMIT EXPIRES 1 YEAR FROMiDATED ISSUED {Complete in Triplicate} 1 #: Application is hereby made.to San Joaquin County for a permit to construct'Iand/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. 1 Ij 1 Jot)Address ALM LOQ AD City 4�5ed!=4 Lot Size/Acreage Q �I,� Owner's Name�RQlol� �,pe,�GlLrl�3 Address Pa' Rex /spzil Z4PO*G l-!t Phone Z Contractor / Addrefs/CD3 W MASH Gc1 57�. license No.5 �7 Pnona (o-eZ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION D SYSTEM REPAIR p I OTHER 13 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 30-1 SEWER LINES NA !DISPOSAL FLD. 6� +f PROP. LINE LA=,f f FOUNDATION AGRICULTURE WELL A4Z4I,OTHERi;WELL-&d-L- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rl n Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation _1b Dia. of Weil Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing— in. ' Specifications F1 Public C1 Other f1 Delta Depth of Grout SeatO Type of GroutAwn-OVA I i Irrigation Approx, Depth DQ Eastern Surface Seal Installed by 4444lt1(f- i�i?L2� �eStlL�'X2` Repair Work Done U Type of Pump ~� H.P. 1 tate:Work Done _ Ili ~ Sealing Material.i Depth.' Well Destruction O Well Diameter .� Depth &1'2 Filler Material i Depth�3�.��/,W . 3 , TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAMIADOkTION { I DESTRUCTION I I IiNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence T Commercial _ Other i I �y E Number of living units: Number of bedrooms y$ Character of soil to a depth of 3 teat: Water loofa depth SEPTIC TANK. ❑ Type/Mfg - Capacity II No. Compartments PKG. TREATMENT PLT. 0 i Method of Disposal Distance to nearest: Well Foundation i Property Lina I� LEACHING LINE 0 No. & Length of lines �3Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ? Property Line ii [ SEEPAGE PITS 11 Depth Size Ii Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ Il ' 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 Calif omis.- Contractor's hiring or sub-contracting signature certifies the following. 1 certify that in the performance of the work for which this permit is isauad, I shall employ persons subject to workmen's compensa- tion laws of California." The applicant must 9all for all requir inspections. Complete drawing on reverse side. i Signed X Title: gz:r-A i0i� _ Date: 1 FOR DEPARTMENT USE ONLY t I 1 Application Accepted by i'Date � f '�`�„_ Area �l Pit or Grout Inspection by Data Final Inspection by '' Date } i, Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services y(� Environmental Health Permit/Services ! 1' �. f,`�� d 445 N Sap Joaquin, P O Box 2009; Stkn,` CA 95201 LJ FEE i i INFO AMOUNT OUE AMOUNT REMITTED ([ASH CK 9 RA�ECEEIVVED BY;� �JDATE� PERMIT'NO. . EH 13.24 IREv.EiM51 � 1� �• � i 'i i`f'` 'Yt k r•4� � 1� � 1931 EH tale lJ LJ 1 I`r