SU0008163 - Laserfiche WebLink

Home Browse Search

n i APPLICATION- FOR PERMIT ( 4 3 m SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES _ ENV1RUNl[ AVE. ,HEALTHPHODIVISION ILE COPY 1601 E. HAZELTON AVPHONE (205)46$-342 P O BOX 2009, STOCKTON, CA 85201 r' I 2MIT-EMIKEn 1. YEAR PROM DATE ISSUND �L- (Complete in Triplicate) • f Application is hereby made to San Joaquin County for a permit to conatiruct and/or install the work herein described. This j application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. WEST SIDE OF HANSEN ROAD - 250 YARDS TRACY Job Address _ SOl lU OF DEI T6 MGN11034 CANAL - City-_- Lot Size/Acreage Owner's Name SAFEWAY, INC. Address 16900 SChui tte,"TRACY 95376 Phone t Contractor NOACK PUMP COMPANY Address 4500 E. FREMONT, STKP� Lit:ense Na. 504513 Phone 948-8817 l.: TYPE OF WELL/PUMP: NEW FELL ❑ WELL REPLACEMENT ❑ DESTRUCTION XXOut of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D , Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES --- DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE r TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r_ 0 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing Pack Xi Domestic/Private ❑ Gravel Pack ❑ Tracy - Type of Casing Speci}ications I I'l Public 3.'1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth t I Eastern Surface Seal Installed by Repair work Done U Typo of Pump H.P. ' State Work Done-DESTROY 6" DOMESTIC O Well Destruction 0 rWell OiamAter aliag Wept'11DRY. QY Depth ,[ � biller Material & Depth �✓ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDlTION t I DESTRUG o septit system'permitted i}public rawer is + i available within 200 loot.) , Installation will serve: 'Residence Commercial Other .� r Number of living units: Numberof bedrooms' t ! r Character of soil to a depth of 3 feet: R e.' Vyalef table depth SEPTIC TANK- D., Type/Mfg Capacity No. Compartments t. I PKG, TREATMENT PLTs❑, t Method•of Disposal Distance to nearest: Well Foundation; . . Property Line a LEACHING LINE ❑- No. 6 Length of lines Total l ngth/size i FILTER BED Distance to nearest: Walt Foundation Property Line r ' ' w SEEPAGE PITS I I_ Depth Sire Number l� i SUMPS ,LI Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ I hereby cenity that I have prepared this applicatlon and that the work will be done in accordance with San Joaquin county ordinances, state laws, ondw. Y rules and regulations of the San Joaquin County / f' Home owner or licensed agent's signature certifies the following; "I certify the fin the.peilormance 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 compensationf California."Contractor's hiring or sub contracting signature laws o certifies the following:"I certify that in the performance of the work for which This permit is issueif;I shall employ persons subject to workman's compensa- I tion laws nia." The applicant mus a�qowl ens. Complete drawing on reverse side. Signed "' Title: RETAIL SALES 1 .Date: FOR DEPARTMENT USE ONLY Application Accepted by O D %c1 Date — A Pit or Grout Inspection by LL Dais Final Inspection b L Dates Additional Comments •1:.�' i�� ILEA s I��Yir�l• �_ T�� t/�l�r0 Yet Applicant - Return all copies to. Ban Joaquin County Public health Services, Environmental. Health Permit/Services 1603. B. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 ! F FEE AMOUNT"bt1E AMOUf4T REMITTED CASH RECEIVED BY DATE PERMIT NO. EK 13-24IRPV.$1 5) EM 1 4•2E r