FIELD DOCUMENTS_FILE 2 - Laserfiche WebLink

Home Browse Search

APPLICATION SAN` JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$--3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This application is rade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 1 Job Address City Tracy Lot Size/Acreage 0-2 ACTeS i 5820 Stoneridge Mall Road, ¢#310 ' Owner's Name SOL1thland Corporation Address Pleasantm, CA 9.4588 Phone (510) 463-2711 V 15 Sf-15 3233 Fitzgerald Street Contractor Address Rancho Cordova CA 95742License No.554979C57 Phone(916) 638-8613 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION R) Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR E OTHER ❑M_1 � gr t Well ) } DISTANCE-TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing aG [1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications l"1 Public (-1 Other fl Delta Depth of Grout Seal Type of Grout I i Irrigation F' _Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. _-- State Work bone Well Destruction Well Diameter 4}1 Sealing Material & Depth Neat C ment from 0-20'(Pressure Depth 20' - Filler Material i Depth Grouted) TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feet.) (� Installation will serve: Residence_ Commercial— Other -r Number of living units: Number of bedrooms rl�Jn11 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED C7 Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 pariormance 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, 1 shall emplpy persons subject to workman's compensa- tion laws of California." The appli nt ustII r II required inspections. Complete drawing on reverse side. j Site ,Pian Attached Signed Title: yl,Wrr++r►aI Sgi✓ii,6 - Date: 9 FOR DEPARTMENT USE ONLY Application Accepted by Date 4�' / Area *3 • D Z- Pit or Grout Inspection by Date .Final Inspection by � ate- � Additional Comments; --- a('-Ji' -- Applicant - Return all copies to: San Joaquin County Public Health Services V Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT'N0. INFO CASH EH 13-21 IREV.i/KSI (pD. , 22.3y ChM �•�•f� ]PD3231p EH 14-26 —