91-1512 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE L'NV I RONTidTNTAL 11TALTII DIVISION 1601. E. HAZELTON AVE. , PHONE (209)468=3211 P O BOX 2009, STOC&TON, CA 95201 ,JUN 13pBgMIT .xP RES I YEAR FR WIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES Application is hereby wade to San Joaquin County, for a permit to construct and/or install the pork hereto described. This application is made in compliance with Ban Joaquin County Ordinance No. 5Ei9 and 1(462 and the Rules and flegu]atione of San Joaquin County Public stealth Servii:es. Jab Address 13170 Grant Line Road/205 S Bron Rd. City Tracy Lot Size/Acreage 62 s4151256-7300 Owner's Name Dividend Development Address 2300 Danville Boulevard Phone Canlraclar L te Environmental Address 4300 Evora Rd., Pittsburgknse No. 057600469 pk,t,n, 415/682-556 TYPE Of WELL/PUMP: NEW WELL WELL REPLACEMENT I l DESTRUCTION Ll Out of Service well Xj OTHER ❑ Monitoring Well w PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE 70 NEAREST: SEPTIC TANK -SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL _..T—, OTHER WELL PITS/SUMPS INTENDEDUSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 2,1 Dia, of Wall Casing LT Industrial CJ Open Bottom ❑ Manteca Dia, of Wall Excavation Scb 40 .0010 lot [.I Domestic/Private � Gravel Pack, $-1 Tracy Type of Casing_ PVC Specifications /Ce ent !'I Ptrhlic C.) Other n Delta Depth of Grout Seal Type o� f Grout Bentonite I I Irrigation Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done 13 Type of lump H.P. State Work Done 11 Sealing Material & D pth 5' Well Destruction C) 2 Well Diameter 25• -- k Depth 25' Filler Material & Depth W 1 YPE OF SEPTIC WORK: NC--W INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it puUlic sewer IS available within 200 loot.) t 0 Installation will serve: Residence�� Commercial_.._,_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: A Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. C7 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of fines Total length/size FILTER RED [=1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certity that I have prepared this apptication and that the work will be dono in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Horne owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, t shall not employ any person in such manner as to become subject to workman's compansalion laws of Celilornia."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 mWC1 alt r uired inspections. Corpplete drawing on reverse side. y (�` Signed X Title;T Date:e 1 ENT USE: ONLY y 3+ 7 Application Accepted by Data z r A I ✓ Pit or Grout inspection by Date 3l Final Inspection by Data Additional Comments: Applicant – Return all copies to,: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hatelton.Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE: AMOUNT REMITTED C K 9 RECEIVED BY DATE f ERMIT'NO. INFO Err 13"2{InEV.r/n51 EH 14.20 5 "