85-267 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH 'DISTRICT 1601 E. HAZELTON AVE., STOCKTON,"' A PERMIT N0. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED- DATE ISSUED _ (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/o'r 'install 'the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 2441C..N. Elliott Rd. Subdivision,Name Owner's Name John Balza;l . Address 24410 N. . Elliott Rd. Phone Contractor's Name Goehrincr Pump- License No. 309031 Phone 1A!7- 5w$ TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS1-1 i. Industrial U OpenyBcttom - ❑.Manteca. Dia, of Well Ex_cavvatio Y ❑ Domestic/Private a ❑Gravel Pack ❑ Tracy~ Dia. of Well Casing y r ❑ Public ❑J Other ❑ Delta Type of Casing i F-11 Irrigation Approx. ❑ Eastern Specifications i ❑Cathodic Protection Depth Depth of Grout Seal ❑ Geophysical ❑Other Type`of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump Sub H.P. 10 State.Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501),� r Depth Filler Material (Below 5O )'. TYPE OF'SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic-.tank or seepage pit permitted if public sewer is �+ 1. z* available within 200 feet.) 9 ; Installation will serve; Residence _ ' Commercial Other Number of living units: Number-of bedrooms Lot size _ m Character of soil to.a depth of 3.feet: - - w c Water table depth F SEPTIC TANK ❑ Type/Mfg;� Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg 'Io., 7Capacity Method of Disposal (j SEWAGE SYSTEM Distance-to-nearest;- Well Foundation. Property Line T DESTRUCTION LEACHING LINE U N0 Length Length of lines `Total length/size FILTER BED ❑ Distance to nearest: Weld Foundation Property Line SEEPAGE PITS �❑- _ Depth 1-. Size Number ' SUMPS 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 Local Health District. 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, 15pJl not employ any person in such manner as to become subject to workmant compensation laws of California." Contractor' sub-contracting signature certifies the followir3g:;"I certify that in the performance of the work for Contractor's hiri which this permit i I shall employ persons subject to workman's compensation laws of California." The applican I r all required inspections. Complete drawing on reverse side, Signed X . ' Title: Bkpg'. Date: 03/14/$5 1F0R DEPARTMENT USE ONLY Application Accepted by Area _ n� ❑ Stk 466-6781 t Additional Comments: — ,Lodi 369-3621 4 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by T d� Date ❑ Tracy 835-6385 ) Applicant - Return all. copies t�onmental Aealt1h Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO k EH 13-24 REV. 10/82 10/82 500 r 14-26