FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

pis APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r4aS iENVIRO �N3 LTH DIVISION 1601 E. HAZLO ELIAVE. ,TAL PHONE (209)468-3420A11�� P O BOR 2009, STOCKTON, CA 95201 neJ _2 Y1T EXPIRES 1 YEAR FROM DATE ISSUEDW. (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the v e 11;his application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rul ons of San Joaquin County Public Health Services. Job Address 141 North El Dorado city Stockton Lot Size/Acreage CM Weber Enterprises/ CA 95818 owner's Name Gertrude WehPr Address 3757 Col lege- Ave. ,,Sacrament_o,Phone - 1561 97 Contractor PC Exploration Address 1780 Vernon St. ,_# E License No. 265556 Phone - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C) DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER [X Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP-ttNIE uil borin FOUNDATION AGRICULTURE WELL OTHER WELL P11_x/StJfu11'S to 30 feet INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1.1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ – hcFF Dia. of Well Casing 1 I Domestic/Private Q Gravel Pack ❑ Tracy Type of Casing_NOne Specifications I'l Public 0 Other 11 Delta Depth of Grout Seal FPPt Type of Grout rPMPnt I I litigation _Approx. Depth I E Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H,P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted it public sower 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 Cl No. 8 Length of lines Total length/size FILTER BED C) Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 cenifies 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 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 11 f I r uired inspections. Complete drawing o�n/reverse side. [� Signed X � Title: Y ��HQa C��F1' Date: /I O FO P SE ONLY Application Accepted by Date Won Pit or Grout Inspection by Date Final Inspection bya G r� Additional Comments: Applicant – Return all copies to: Ban Joaquin County Public Health Services, Environmental Health Permit/Services / 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ASR–] RECEIVED BY DATE Q PERMIT'NO.O. . EM 1331,iPfv.I�xs1 W71