SITE INFORMATION AND CORRESPONDENCE

Home Browse Search

i ri .. APPLICATION FOR PERMIT y SAN JOAQUIN COUNTY PUBLIC HEALTH VICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)465-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FIR DA � sF'D � t (Complete is Triplicate) Application is hereby mads 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 Sar: Joaquin County Public Health Services. J. Job Address 4555 N._4Pershina Avenue City_ Stockton Lot Size/Acreage Boettcher Western 825 17th Street, Suite 400 Owner's Name Address enve ,_('oi radn•. Phone – 85 47'-Louise Street contractor Precision Sam lin Address San -RafaelLicense No. 631%3 =]_Phone - 987 TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Weil 0 PUMP INSTALLATION❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [X DISTANCE TO NEAREST: SEPTIC TANK N A SEWER LINES 40 ft.-_– DISPOSAL FLO._N/A PROP. LINE _. - ft. FOUNDATION 20—ft• AGRICULTURE WELL NIA OTHER WELL_Z5_,ft_ PITS/SUMPS NJ_A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing N/A Gl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing N/A Specifications 1'1 Public IR Other n Delta Depth of Grout Seal 26 ft. Type of Grout Cement _ I I lrrivation I6Approx. Depth l I Eastern Surface Seal Installed by N/A__ Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction U Well Diameter 3 inch_- Sealing Material & Depth neat cement t. L-A Depth _ 26 __ Filler Material A Depth N.1 A ___ tf� TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted if public sewer is YN available within 200 feet.) Installation will serve: Residence— Commerciaf— Other Number of living units: Number of bedrooms _'V Character of Soil 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 Ci No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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 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 t0 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 taws of California." The applicant must call or all required inspections. Complete drawing on reverse side. Signed �p .fly[ ,. _ Title: Date: y _ _ > I FOR DEPARTMENT NLY !!! ? 1 ? Application Accepted by r`M ` Date_25L) f yr ' Area Pit or Grout Inspection by Data Final Inspection by Date j Additional Comments: Applicant – Return all copies to: Sea Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEEi INFO AMOUNT DuF AMOUNT REMITTED K H RECEIVED BY DATE PERMIT NO. . EH 19.21(REV.s i w sr f' U ( �� .;L6 i �� // EH 1�•2a