FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

. � avPl_IG••T?ON �� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH D : 3ION 445 N SAN JOAQUIN, PHONE (.'x:3)468-3420 P O BOX 2009, STOCKTOiti, 1.A 95201 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete is Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in cmVllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 2130 West Washington Street City Stockton Lot Size/Acreage Job Address Owner's Name Port of Stockton Address P.O. Box 2089, Stockton, CA Phone (209) 946-0246 Sierra-Pacific Groundwater 4911 Wlndplay Drive, #4 /Contractor Consultants, Inc. Address El Dorado Hills, CA License No. CEG 1133 Phone (916) 933-1468 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O Monitoring Well SYSTEM REPAIR ❑ OTHER J C3DISTANCE TO NEAREST: SEPTIC TANK N p' SEWER LINES NSA DISPOSAL FLO. N/A PROP. LINE 200 feet FOUNDATION N/_ AGRICULTURE WELL _.N/—A OTHER WELL N/A PITS/SUMPS N�A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N/A Dia. of Wen Casing Cl Industrie) ❑ Open Bottom ❑ Manteca Dia. of Wag Excavation — 0 n Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing none Specifications �J Pl Public P Other M Delta Depth of Grout Seal lll Typo of Grout Bentonite IC-11) I I Irrigation —Approx. Dept/Al I Eastern Surface Soul Installed by Repair Work Done U Type of Pump M.P. $tate Wort Done_ N/A Sealing Material k Depth Bentonite Wed Destruction C3 Wed Diameter Depth N/A Tiller Material 4 Depth Bentonite TYPE OF SEPTIC WORK. NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION t 1 INo septic system permitted if public srwar is available within 200 feet.) installation will serve: Residence_ Commercial_ Other NOT APPLICABLE Number of living units: Number of bedrooms Character of soil to a depth of 3 fact: 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 ❑ No. b Length of fines N/A Total length/size FILTER BED ❑ Distance to nearest: Wed Foundation Property Lino SEEPAGE PITS I I Depth N A Size Number SUMPS Ll Distance to nearest: Wed Foundation Property Line DISPOSAL PONDS ❑ 1 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 certifies the following:*1 certify that in the performance of the work for which this permit is issued. I shall not employ any parson 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 peRormance of the work for which this permit is issued,I shad employ persons subject to workmen's compensa- tion taws of California." The applicant t ca au required inspections. Complete drawing on reverse side. Signed _(J7T;v<,• Senior Engineering Geologist Cate: FOR DEPARTMENT USE ONLY Application Accepted by Dal o Area 3 Pk or Grout Inspection by Date Final Inspection by Date Additional Comments: ,5xle� Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 443 N San Joaquin, P O Box 2009, Stka, CA 95201. FEE AMOUNT DUE AMOUNT REMITTED CK s CASH RECEIVED BY DATE PERMIT'NO. (NFO . EM 13-24(Itev_I/WSJ Q i •✓ [ ✓•��