COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application 1s hereby Crede 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. Job Address 1245 W Wahar AUr' _ City_$t aCktanLot Size/Acreage Owner's Name _ Bank Of S tovckton Address Box 1 1 10 Phone Contractor West Hazmat Address 3233 Fitzgerald License No. 554979 Phone,9 76 TYPE OF WELL/PUMP; NEW WELL C1} WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK n/a SEWER LINES J Q0 F DISPOSAL FLD. PROP. LINE 101 FOUNDATION 9L11 AGRICULTURE WELL OTHER WELL nn t PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Ole. of Well Casing 4 " f I Domestic/Private I Gravel Pack ❑ Tracy Type of Casing SChed 40PVC Specifications 11 Public *1 Other sand pkfl Delta Depth of Grout Seal 9 1 Type of Grout .at g 1 , r_ 11 Irrigation 2.5,,Approx. Depth I I Eastern Surface Seal Installed by rlri 112*' Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material a Depth t•.,.. — E15 r Depth Filler Material i Depth sand_to 251 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I permitted if public sewer is Installation will some: Residence _ Commercial_ Other RELbeIVED feet.l Number of living units: _ Number of bedrooms DEC 0 9 t9��90 Character of soil to a depth of 3 feet: Water to a depth SEPTIC TANK ❑ Type/MfgSAN Jr' Capacity No. CompartrFie�its PKG. TREATMENT PLL ❑ —PQBC7�r':.: Gr ENVIRONNILN i A4athod of 0 f to Distance to nearest: Weli Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size__ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 workmen's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "1 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 Cali rola." The applicant st ca for all to aired inspections. Complete drawing on reverse side. Signed X____g Z-- Lt VL _ Title: Brn 'nr•+ Geologist----� Date: I t i 7;'n 1 FOR DEPARTMENT USE ONLY Application Accepted by .. Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Frivironmental Health Permit/Services 1601 E. Hatelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNTOt1E AMOUNT REMITTED INFO CASH RECEIVED SY DATE PERMIT NO, Fir U]/IaEV 11x51 FH a]a