84-1142 - Laserfiche WebLink

Home Browse Search

f APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 F y PERMIT EXPIRES 7 YEAR FROM DATE ISSUED rr! (Complete in Triplicate) A~ Application is hereby made to the San Joaquin Local Health District 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 far sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin P � eal$i'°�Strict#''� .Sa tnS' Ranch Unit # 5 NW Job Address 'corner o Lot 29� "lip ►.�r�k.. Tracy 40tx60: YEW-Ea— ..�.=cs/ Lot Size PM s—31-9 Owner's Name W• `Dawe Qlmstea " 4 d Address PO BOX 134 Tracy — Phone 835 ?284 Clark Well '& ,p � � Contractor's Name License No. 371560 452_5597 TYPE OF WELL/PUMP: Phone >c NEW WELL E* WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLAIT�J11 SYSTEM REPAIR ❑ a OTHER ❑ DISTANCE TO�NEAREST:"SEPTIC TANK' o SEWER LINES 3(� DISPOSAL FLp PROP. LINE FOU N DAT10 N{ AGRICULTURE WELL OTHER WELL PITS/BLIMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS © Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation 1�j n WWW ❑ Domestic/Private X] Gravel Pack $1 Trac Ste Dia. of Well Casing C Y Type of CasingSpecifications 6 ' D Public ❑.Other ❑ Delta Depth of Grout Seal © , 4 sack ❑ Irrigation --q Type of Grout �I r ---Approx. pe th Eastern Surface Seal Installed by car Repair Work Done ❑ Type of Pump �Or bine H.P 60 S a Well Destruction ❑ Well Diameter 1 State Work Done Sealing Material (top 50,)' Depth I Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is k 1 " r Installation will serve: Residence_ Commercial available within 200 feet.) Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: , ` } SEPTIC TANK Water table depth ❑ Type/Mfg Capaci PKG. TREATMENT PLT. ❑ tty No. Compartments Method of Disposal Distance to nearest:' 'Well Foundation-- Property Line ,., 4 " 1w....+ LEACHING LINE i ❑ No.`& Length of lines "FILTER BED°� '�'�` � Total length/size " ❑' Distdnce to nearest:' Well Foundation Property Line 1 �f► SEEPAGE PITS c❑ Depth Site SUMPS r t Number ❑ Distance to neerest- Well Foundation i DISPOSAL'PONDS i ❑ Property Line 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 theTSan Joaquin Local Health District. t c 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 a orae subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"!cern in the nae of the" for which this tion laws of California." permit is issued,I shall employ persons subject tv workman's compensa- tion appfican st II f all re ire pec i< ple drawing on arse id . Signed Title: f Date: t FOR DEPARTMENT UPE ONLY Application Accepted by • /# r. . G _ Date �.. Area G Pit or% ^ Final Ins coon b Grout Inspection by Date 7 y Dat _a y D x- Additional Comments: S ❑ Sik 466-6781 ❑ Lodi 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CAFEE 95201 INFO AMOUNT DUE }AMOUNT REMITTED C K RECEIVED BY DATE ' PERMIT`NO. + EH 1324{REV.10/831 EH 14-26