FIELD DOCUMENTS - 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-0 BOX 2009, STOCKTON , CA 95201 - EXPIRES 1 YEAR FROM DATE l � (Complete In Trlpllcate) Se hereby made•to San Joaquin County for a permit to construct and/or install the work herein described. This Application with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San application is lade in compliance Joaquin County Public Health Services. Stockton Lot Size/Acreage 33 acres 535 Center Street O'ty----- Job Address Ph.,,J415) 465-1116 a Ft Pctric Address One California Street Owner's Name - San Francisco, CA 94106 Attn: Yvonne Meeks North HigQhlands JQL291 Phn4 ol i k Dr• 11 ins 1nc.Addiess 3429 Longview Dr. 95f,F,❑_LicBns DESTRUCTION ❑ Out of Service well Contractor wWCI ❑ NEW WELL ❑ ELL REPLACEMENT 2Monitoring wells TYPE OF WELL/_ PUMP: SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION O PROP. LINE — (MW-5 & SEWER LINES �" 150r DISPOSAL fLD.Ni- MW-6) DISTANCE TO NEAREST: SEPTIC TANK ti 70r OTHER WELL PITS/SUMPS ._ Map AGRICULTURE WELL See FOUNDATION TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS NS es 4 inches INTENDED USE Dia. of Well Casing ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications Attached_ ❑ Industrial Type of Casing PVC Pit Gravel Pack ❑ Tracy Cement C.I Domestic/Private Depth of Grout Seal 85 f_ ee—t— TVPa of Grout [-1 Other fl Delta �, UI Public Surface Seal Installed by i I Irrigation 1QQ'Approx. Depth 1 I Eastern State Work Done _ Repair Work Do U Type of Pump None H.P. Sealing Material i Depth Well Destruction ❑ Well Diameter Filler Notarial 6 Depth Depth�� is available within 200 feet.) INci TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I ava septic system permitted it public sewer r other Installation will serve: Residence_ Commercial._ � Number of living units: _ Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal r i PKG. TREATMENT PLT. ❑ Foundation Property Line Distance to nearest: Well Total length/size Distance LEACHING LINE Cl & Length r eines Foundation Property Line FILTER SED CI Distance to nearest: Well SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby cenify that I have prepared this application and that the 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 or subcontracting 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 ��musst call for all r uired inspe, awns. Completed, on reverse stq{Le� ^ �I�\ 00 �: Title: A � Dale: t_ Signed X_� ��rl� ( FOR DEPARTMENT USE ONLY �C-7 'Area Application Accepted by ( , ?d (lZ Pit or Grout Inspection by tj�t' p` Date '- Final Inspection by �IL� - Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Enviropmental Health Permit/Services CA 95201 Z�1' Suis 1601 E. Hazelton Ave., P 0 Box 2009. Stockton, FEECKs RECEIVED BV DATE PERMIT N0. AMOUNT DUEFAfIAREMITTED _ A/SH ��t7�t` INFO oc) (.al 60' 1/" � 9 wll. JE� 6N IREV.vnv ♦V EN r.za