87-3529 - Laserfiche WebLink

Home Browse Search

a a j APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 # PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. E. Job Address 4860„Woodbridge Rd. _ city Acampo Lot Size PM Owner's Name Mr.:=I 'K05k, w_<._=_ . Address 4Woodbri dge Rd. Phone Lockeford Contractor Goehrng Pump Address 7 5 T License No. 309031 Phone 727-5548.,,q., 27-5548 {' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ 1i PUMP INSTALLATION LJ SYSTEM REPAIR ❑ OTHER-'9C "��? DISTANCE TO NEAREST: SEPTIC TANKf SEWER LINES DISPOSAL FLO. - PROP. LINE FOUNDAT.IUN_ ;AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM'AFiEA CONSTRUCTION`SPECIFICATIONS— - ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other F.1 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done -. 7 Type-of-Pump.. --State Work--Done e P P Well Destruction „E-) :,Well Diameter Sealing Material (top 501 Depth Filler Material IBe Ow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Irl REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial--"—Other-* a Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 'f 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, I shall not employ any person in suc anner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: " rtify 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 Calif The applicant or required inspections. Complete drawing on re2v*.f Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area r I Pit or Grout Inspection by Date Final Inspection by v Date�P Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE A NT REMITTED CK RECEIVED BY DATE PERMIT�NO, j INFO CASH + EH13-24(REV.1i05) EH 14-26 3