93-0029 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT I' SAN JOAQUIN COUNTY PUBLIC REALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 2EUITEXPIRES_I YEAR„ERQU RAIE ISSUED (Complete in Triplicate) Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This application is made in eoapliance with sort Joaquin County Ordinance No. 51+9 and 1862 and the Mules and Regulations of San Joaquin County Public Health services. Job Address 5400 Pacific Avenue City St-orkr_nn Lot Site/Acreage Owner's Name -Montgomery._W,a. r.,d _' h Charlie Jest Address 920FtPrCtt Phone (41.5 79GA-29 1777 Contractor -- --=gddPQ, Y /7�Z� _ License No. C57-9-00/1 Pt+ene 916 6 .'-�� TYPE OF WELL/PUMP: NEW WELL. 0 w WELL REPLACEMENT Cl DESTRUCTION 0 Out of service dell ❑ i PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER © Monitoring Well Yy DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 0-150 ft DISPOSAL FLD. PROP. LINE �C FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavatio �6� � Dia, of We" Caring U Dornselie/privet! O Gravel Pock7 ❑ Tracy Type of Casing_ Specifications $1 Public Hother Boring�n Delta Depth of Grout Seal �y T�YPILOf Grout rem I I brig+tion 5atLpprox. Depth 1 I Eastern Surface Seal Installed by Rspsh Work Done 0 Type of Pump H.P. State 1Nork Cfanr Well Destruction O Won Diameter Sealing Material ! Depth eat ement Slur- t- ottom) Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AOOITION 1 I DESTRUCTION I I [No septic system permitted It public sewer In available within 200 feel.) ' Installation will terve: fiveidence_ Commercial— tither Number of Qvhng units: Number of bedroomt Character of sole to a depth of 2 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKO. TREATMENT PLT.O Method of Disposal Distance to nearest; Well Foundation Property Line LEACHINO LINE 0 No. S Length of lines Total length/sirs FILTER BED 0 Distance to nearest: Wel! Foundation Property L FrF 6 -K.L� SEEPAGE PITS1 1 Depth Slra Number t SUMPS LI Distance to neareet: Weft Foundation Property.Ljna:r_lt.03,1 y DISPOSAL PONDS D 3 I hereby certify that 1 hove prepared this application and that the work will be done In accordance witN'S*t1'5d1ltfd6 bkfuhlt 'ordinsnees, stale laws, and rules end regulailons of the San Joaquin County Home ownar or licensed agent's iignsture certifies the following: "I certify that In the performance of the work for winch this permit Is issued, 1 shell not employ any person In such manner as to become subject to workman's compensation laws of California."Contractor's Ewing Or sub-contracting signature eerlHisa the following-"I certify that M the perfemsance of the work for which WE permit is issued,I shall employ persona subject to workman's compensa- tion laws of California." The applicant stcall for all ked Inspections. Complete drawing bn reverse side. See Attached k figure S4 0 Title: Geologist Dots: 11/30/92 FOR DEPARTMENT USE ONLY g !� Application Accepted by Dote - ` 3 Area ! Ph or Grout tnapectbn bynote2 Final Inspection by Date Add onef Comments: i Applicant - Return all copies to: Ban Joaquin County Public Health Services Stiviroamental Health Permit/Services 79 445 N BED Joaquin, P O Box 2009, Stkn, CA 85201 INFQ AMOUNT DUE AMOUNT REMITTED CASH CK I RECEIVED sY 11-- AMOUNT PEAMIT'Np. S V 'J L EH tL� CCJJ F