FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN ..JAQUIN COUNTY PUBLIC HEALTH nRVICES ENVIRONMENTAL HEALTH DIVISION t56 5 v 445 N SAN JOAQUIN, PHONE (209)468-3420 Ap Z P O BOX 2009, STOCKTON, CA 95201 2,0 -: , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �^) TFY� (Complete in Triplicate) Application is hereby made to San Joaquin County for a perrlt to construct and/or install the work herein described. This application is m de in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin county Public Health Services. Job Addreas 1624 East Alpine Avenue city Stockton Lot Size/Acreage (Associated with Kearney KPF) Owner's Name . The Croydon Compafl.v> Inc. Address 1624 East Alpine Avenue Phone (209) 464_ QIJAL A'tE2 93380 Contractor ,li-=—'" tr =Well Address POBOX 80537 6akersf=elm CA License No. 501117 G-paig TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT t1 DESTRUCTION XA Out of service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications R, I'I Public ❑ Oliver ❑ Delta Depth of Grout Seal Type of Grout �. I I Irrigation —Approx. Depth I 1 Eastern Surface Seal Installed by y Repair Work Done ❑ Type of Pump H.P. State Work Done _ Sealing Material i Depth Neat Cement 5 - q fppt p Well Destruction �X Wall Diameter 4-inch "! Depth Filler Material L Depth Soil 0-5 feet TYPE OF SEPTIC WOflK: NEW INSTALLATION I I REPAIR/ADDITION I I 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 ii to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments 1(p' PKG. TREATMENT PLT. ❑ Method of Disposal C Distance to nearest: Well Foundation Property Line y LEACHING LINE ❑ No. 6 Length of linea Total length/size FILTER BED ❑ Distance to nearest: Wall Foundation Property Line SEEPAGE PITS 11 Depth Size Number _ SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t I hereby cartify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and �L rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifles the following: "I certify that in the performance of the work for which this permit is issued, I shell not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub�contracbng signature certifies the fol owing: "1 oarti that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compsnsa tion law.of Californla." The appfica t mu o uired, speclions. Complete drawing on reverse side. Signed (L Title: Hvdrogeologist Data: 9 August, 1993 ota a ssocla-tea, Inc. FOR DEPARTMENT USE ONLY Application Accepted by Data Area p Pit or Grout Inspection by Date Final Inspection by u Date ') Additional Comments: if Applicant - Return all co to: San Joaquin un P11 4 alth Services / x Environment Health Per /Services d G 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASN RECEIVED By DATE PERM17 NO, INFO . EH i124(REV.t r a sl beep EH 14-20