Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COIINTY PUBLIC SEALTH SERVICES <br /> RNVIRONMEWAL HEALTH DIVIGION <br /> 1601 X. HAZELTON AVE. , P90MB (208)488-3420 <br /> P O 801 2009, STOCE'i'Oi[4, CA 8$201 <br /> PSRUIT RXPIRRS 1 YEAR FROM DATE I2A <br /> a <br /> (Complete in Triplicate) <br /> Application is hereby mado to San Joaquin County for a permit to construct and/or install the work berein described. This <br /> application is made in compliance vlth San Joaquin County Ordina"it Mo. 549 and 1862 and the Rulea and Regulations of Baa <br /> Joaquin County Public lfaalth Services. <br /> Job Address 1448 Ala El_ Dorado_Street _ city Stockton __ Lot Size/Acreage 1 <br /> Owns s Narm _Wickland ^Prove;tlefa Address 1765 Q4112171M W 9MOMMtO CIA Phone 1'916 921 1 <br /> � y <br /> 95650 95815 <br /> I Contractor "=to' bmlor mti= Address 3242 03mms R3 iarnns- 0 License No 401539 C 52__Phone 1916 652 464( <br /> TYPE OF WELL/PUMP NEW WELL = WELL REPLACEMENT n DESTRUCTION 0 Out of Service veli ❑ <br /> PUMP INSTALLATION C SYSTEM REPAIR M OTHER G Monitoring Well IIs <br /> DISTANCE TO NEAREST SEPTIC TANK N A--_ SEWER LINES 50 O,SPOSAL FLO N_ PROP LINE 15 <br /> FOUNDATION 30 AGRICULTURE WELL V A OTHER WELL 45 PITS/SUMPS N A <br /> INTENDED LISE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ($Industrial 0 Open Bottom ❑ Manteca Dia of Well Excavation S' Dia of Well Casing ?' <br /> r 1 ow"aatic/Privato 9)Gravel Pack ❑ Tracy Type of Casing Specnccauors E t^= 4'}' An <br /> I I Pttbkt I 1 Other M Delta Depth of Grout Seal ,1S TYPe of Grout <br /> I I trmgation —Appros Depth I I Eastern Surface Seal Installed by <br /> Repan Work Dom 0 Type of Pump HP Slate Work Done_ <br /> Well Oeatructran ❑ Well Diameter Sealing 16atorial a Depth <br /> Depth Pillar Hatevial A Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION i i REPAIRrADOITION I I DESTRUCTION I I INo wpiec system permitted it public sewer m <br /> avarleble within 200 feet 1 <br /> Installation will serve Rtlaldo W.,,„._ Commoretol,„.,.., Other <br /> + Number of jeering umM Number of bodroomo <br /> '~ Chmactor of cal to a depth of 9 Not Wstor toblo depth <br /> SEPTIC TANK O Typo/Mfg CaMacny No Cornpartmonts <br /> PKG TREATMENT PLT ❑ Mottled of Disposal <br /> Distance to noaroar Well foundation Ptoporty Lem <br /> LEACH.NG LINE Cl No A Lonoth of linos Total length/sitze <br /> FILTER BED ❑ Distance to nearest Wap Foundation Property Line <br /> SEEPAGE PITS 1 I Depth Sire NurAbor <br /> SUMPS Ll Orsteneo to narreat Well Foundation_ _ Property Late <br /> DISPOSAL PONDS D <br /> 1 hereby certify that 1 have propsred this app4cetion and that the work will be dorsa in accordance with San Joaquin county ordinances state taws end <br /> ruWt1 and regulations of the San Joaquin County <br /> Home owner at beenead agent's signature certifies.the following I coftIV that in the performance of the work for which this potent to issued, 1 shatl not <br /> employ any person in such mariner as to become subject to workman a compensation laws of California Contractor's hiring or subcontracting slgmature <br /> cartifini ffe folowang 9 eottify that in(fie psrformence of the work for wtueh this permit is issued,i shall employ persons subject to workman a compeers <br /> lion lawn of California" <br /> Tho applicant nest cap for ON taquired inspectons Complete drawing on rovorso side <br /> Signed K.– Title Date 8 13 91 <br /> FOR DEPARTMENT USE ONLY <br /> Anplication Accepted by Date — Arca <br /> Pit or Orout Inspection by Date_ Final Inspection by Data�..,.,.�. <br /> Additional Comments <br /> i Appll"At – Return Ilia copies tot San Joaquin County Public Health <br /> i Services. 4r1ronmsntal Health Permit/Services <br /> 1601 Z. Reselten Ave.. P 0 Sox 2009. Stockton. CA 95201 <br /> INFO AMOUNT out AMOUNT REMITTED CASH <br /> a RECEIVED BV OATE PERMIT NO <br /> [t417 ss.IrEY � .Si <br /> , <br /> — <br /> 3J <br />