FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

1 • APPLICATION FOR PERMIT • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION -' 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOR 2009, STOCKTON, CA 95201 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made 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. 5L9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 200 Block of Market St. between Madison City Stockton Lot Size/Acreage and Van Buren Streets Owner's Name Pacific Gas & Electric Address One California St. , Phone (415) 972-1116 - - San Francisco, CA 94106 Contractor Spectrum Exploration Address 2825 Myrt7 Stockto02icense No. 512268 Phone(209)46 -R77 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 3 Monitoring Well (IDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES L 50' DISPOSAL FLD. PROP1LINerehole (B-23) see map FOUNDATION AGRICULTURE WELL OTHER WELL �,7 PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS bete ROES00112 aSSOmed_to L1 Industrial bit ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casi Sng [.I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public fl Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done _ L VVatf Destruction ❑ AIM Diameter 10inch es Sealing Material i Depth Cement grnnr rn 95 foal- (, Borehole Depth 25 feet Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I fNo septic system 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 ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS II Depth Size Number SUMPS LI Distance to nearest: Wall Foundation Property Line DISPOSAL PONDS ❑ 1 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature 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 must call for aJJ raequiuired pections. Complete drawing on reverse side. YA Signed X�� Y Title: Date: / FOQ. R EPAR MEN SE ON YL- 9Twz -q1 C Application Accepted by �2-3 ��11 Date Area K -7 Pit or Grout Inspection by Date 2^ 'M Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK a flECE1VED BV O` ✓% INFO // //�� CASH DATE PERM17NO. EM U 20(REV.irx 51 �v), GCS 11 EN 13-24 ��``JJJJJJ 11