91-0028 - Laserfiche WebLink

Home Browse Search

j q APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PAV1.'; . 111iT P O BOX 2009, STOCKTON, CA 95201 R E C E I V E D (249) 468-3447 .P MIT EXPIRES _I MME ?ROM, 12ATE Issulm DEC 17 799G (Complete in Triplicate) Application is here made to San Joaquin Count for tg1y1� WLT1Aibk*AL�a � by q y permit to construct and/or install the vo application ie.made in ccatpliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules k� of Ban Joaquin County Public Health Services. Yob Address 1051 SPERRY ROAD City STOCKTON Lot Bite/Acrea;ge' V (209)wner's Name JM MANUFACTURING Address 1051 SPERRY ROAD Phone 982-1500 . Contractor OWNER Address License No. Phone o TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well r� PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ Monitoring Well C1 U° DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing x �� G Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public lel Other ❑ Delta Depth of Grout Seal Type of Grout 0 Irrigation -„�.Approx. Depth ❑ Eastern Surface Seal Installed by I Repair Work Done U Type of Pump H.P. State Work Done ._ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ R AIR/ADDITION M DES UCTION CI (No Septic system ` p permitted if public sewer is available within 200 feet.) Installation will serve: Residence—..-_ Commercial Other Number of living units: Number of bedrooms - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Fou n ion Property Line SEEPAGE PITS 11 Depth 5i: Number SUMPS Ll Distance to nearest: ell Foundation Property Line DISPOSAL PONDS ❑ I hereby canify 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 California." Contractor's hiring of sub-contracting signature f -- certifies the following: `'I 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 California." The applicant mu t c 11 r all required in ctions. Complete drawing on reverse sid Signed r 14 Title: Date: a FOR DEPARTMENT USE ONL ? i Application Accepted by nate " ... Area Pit or Grout Inspection by Date Final Inspection by Date Additional Command Applicant- Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 i FEE MOUNT DUE MpUNT REMITTED CK RECEIVED BY GATE PERMIT'Np, INFO CASH . r EH t3.2{IAEV.iin5s EH 144 ` V - � y