SR0001867 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PER ` SAN JOAQUIN COUNTY PUBLIC aEFAAH S 1 ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE U46 - P O BOX 2009, STOCKTO 4, A 95201 �_- LV 1 1JJ (Complete in Tripi�� Application is hereby made to San Joaquin County for a permit to const or install the work herein described. This mpplication 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. Job Address 1812 Monte Diable Ave. City Stockton Lot Size/Acreage 1 -ACRE Owner's Name Russell Chapin Address 1201 N. Carlton, Stockton Phonj 209) 464-434 (800) contractor Geo-EnyironmentalAddress P•0. 3595, Yuba Cityicense No. 676923 Phone671-2424 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER i Monitoring Well )CX DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 30 f t . DISPOSAL FLD. PROP LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C) Industrial (I Domestic/ Private !'I Public I I Irrigation Repair Work Done U Well0-3struction ❑ TYPE OF SEPTIC WORK ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8 irieh_T Dia. of Well Casing 2 in Ch N Gravel Pack ❑ Tracy Type of Casing_ PVC Specitications 0 • 020_ S c r e Cl Other 1-1 De',ta Depth of Grout Sezi 12 f t . Tyrr of Grout Neat Cemen Ap;xox. Depth I I Eastern Surface Seal Installed by Drillers _- Type of Pump H. P. State Work Done _ Well Diamater Sealing Material i Depth Neat C e m e n tom. - ft. Qepth Filler Materiel i Depth #3 Monterey Sand - 14 ft. NEW INSTALLATION I I REPAIR/ADD!TION I I DESTRUCTION I I (No septic system permuted it puhltc ;ewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of Irving units: NunO.er of bedrooms Ctaracter of soil to . dc-oth -.-f 3 :set: SEPTIC TANK O Type/Mfg Capacity PKG. TREATMENT PLT, Cl Distance to ndarest: Well LEACHING LINE ❑ No. dt Length of lines F'LTER BEC f.1 Distance to nearest: Well SEEPAGE PITS I Depth --- Size SUMPS LI U;stance to nenrest: Well DISPOSAL PONDS ❑ '•oundation Foundation Water tante o ptn _ No. Compartments Mothod cf Disposal Property Line - _ _.— Total length/size Property Linc __ - , - Number Foundation __ Property Line I hereby certify that I have prepared this appiication and that the work will be done in accordance with Son Joaqu�n counr., ordinances, state tows, and rules and rogulal nns of the San Joaquin County Home owner or licansed agent's signature certifies 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 subyect to workman's compensation laws of California." Contract ' contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall ov persons zeibject to c compensa- tion Isws of California." o0 \ Q b The appl' n ust call for all r inspections. Complete drawing on reverse side. J y v n Signed Title: /►^ -- --- Data:_0 _/-L ----- FOR DEPARTMENT USE ONLY Lj Application Accepted by Date (V30/93 Area Pit or Grout Inspection by � � Date l I I -� 1 S F,iin{al Inspection by /� Uatc _ 1417 Additional Comments: 6-c4J--J-0<-1 . . -19 Applicant - Return all copies to: San Joaquin County Public Health Services ,— Environmental Health Permit/Services 445 N Sen Joaquin, P O Box 2009, Stkn, OA 95201 l> EH 17.24 1REV, t i A!; ell 14 _V FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PCRMIY'NO.67 n tai r"N r�