FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMENT ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 RECEIVED P O BOX 2009, STOCKTON, CA 95201 JAN 15 1993 PERMIT EXPIRES 1 XM FROM DAIE ISSUEDSAN JOAQUIN COUNTY (Complete in Triplicate) PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION Application is hereby made to San Joaquin County for a permit to conatruct and/or install the work herein described. This application is made in eoWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 711 Pershin Avenue City Stockton Lot Size/Acreage 0.87 acre Arthur J. Snelt 5461 Covey Crk. Circle, Stockton 478-3218 Owner's Name Charles DeVries Address 23613 E. River Rd. , Escalon Phone 838-2300 Rancho Cordova, CA 9567Q Contractor Address Industries Address 3164 Gold Camp Dr. ,#200 L(cense No. N/A pitons (916)852-66 0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Ye11 ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER IN Monitoring Hell ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bortam ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing n/a n Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing n a Specifications Il Public n Other n Delta Depth of Grout Seal lu t• Type of Grout vest Cement I I Irrigation —Approx. Depth i I Eastern Surface Semi Installed by Contractor Repair Work Dome 0 TYPO of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Piller Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION I l DESTRUCTION I I (No septic system permitted-if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ;. Number of living units: Number of bedrooms ` Character of=A 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. A Length of lines Total length/size I' "N. FILTER BED ❑ Distance to nearest: Well Foundation Properly Line SEEPAGE PITS It Depth Size Number— SUMPS umber,SUMPS C1 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 canities 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 i 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 spplica st call for all required inj�itrons. Complete drawing on reverse side. Signed x_, A/ Title: Geologist Bate: 1/8/93 FOR DEPARTMENT USE ONLY Application Accepted by Date Are& 2 Final Ins coon b Date �l Pit or Grout Inspection by Date Y Additional Comments: /10 e /o' Applicant - Return all copse to: San Joaquin County Public Health Services 50 Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stka, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED By PATE PERMIT'NO. INFO 9 / +� / 9 ��]J . EH 13.24(REV.t/ SI 9 ¢Q / 1i • �/ "� ✓ DD fm 14.28