SU0008852 SSCRPT - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT - SAN .JOAQUIN COUNTY PUBLIC HEALTH SERVICESA�, : r .N° ENVIRONMENTAL HEALTH DIVISION �=-_AIN 1601 E. HAZELTON AVE. , PHONE (209)468-3424 P O BOX 2009, STOCKTON, CA 95201 pR1T�' SXPIRSS ] YSAR 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 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 tri 475 W. BLEWETT ROAD __ City TRACY___ Lot size/Acreage Owner's'Name C&A NAVARRA RANCH Address 475 W. BLEWETT ROAD, TRACY Phone 885`0005 Contractor NOACK PUMP CO. Address 4500 E. F'REMONT, STKN Li[ense Ivo. 504513 Phone 948-8817 TYPE OF WELL/PUMP-- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 F] Industrial 0 Open Bottom ❑ Manteca Dia- of Welt Excavation Dia. of Weil Casing EI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public Ell Other n Delta Depth of Grout Seal Type of Grout XI lrrigation _Approx. Depth I I Eastern Surface Sea] installed by Repair Work Done U Type of Pump 11IRBll11F H.P. TQn _- State Work Done INSTALL TIIRB INE PTP Well Destruction O Well Diameter Sealing Material & Depth IN_Isi[J.f Depth Piller Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public seuver is available within 200 feet.l Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soft to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Two/Mfg Capacity No. Compartments PKG. TREATMENT PLT. El Method of Disposal Distance to nearest: Well foundation Property Line oe- LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED D Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ l hereby cenity that I have prepared.this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, andQ rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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,I shall employ persons subject to workman's compensa- tion laws of California." The applic ntust 11 for 11 equirad ' p ti mplete drawing on reverse side. Signed D 0 C `rtle: RETAIL— SALES Date: FDR DEPARTMENT USE ONLY Application Accepted by Date ' Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health-Permit/Services 1601 S. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FCE r, INCA AMOUNT DUE AMOUNT REMITTED CASH RECEIVED SY DATE PERMIT-NO. . EM 13-24[REV.iin5) $q< �` ,ir, L'QL 1 L —f� 11.^39 -EH;i-je