Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 4860 E. Woodbridge Rd city Acam o Lot Size 4 : 5 acres PM <br /> Owner's Name Paul Baumbach Address same Phone 334-4899 <br /> Contractor Clark Address 2024 E. Charter Way License No.371 560 Phone 462-7676 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATIX SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 10 0 1 SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1L Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1� <br /> I I Irrigation —.-Approx. Depth l I Eastern Surface Seal installed by _ Cj <br /> Repair Work Done ❑ Type of Pump Sub H.P. 3 State Work Done Install <br /> Well Destruction NX Well Diameter 811 Sealing Material (top 50') 9 Sack m <br /> Depth 1 80 Filler Material (Below 501 Same <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.] r <br /> Installation will serve: Residence_ Commercial_ Other G <br /> Number of living units: Number of bedrooms Q <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT.PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line R <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS L-I Distance to nearest: Well_ Foundation Property Line ` <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> rules and regulations of the San Joaquin Local Health Di$trict. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performa ce of the work for which this permit is issued, I shall-employ-persons subject,to-workman's compensa- <br /> tion laws of Califora �i <br /> The applican sl f al qui ct' ns. mplete drawing on reverse side. <br /> Signed X Title:VP Clark Date: 31 Aug 1988 <br /> FOR DEPARTMENT USE ONLY /, / <br /> Application Accepted by �77t l [�� -- Date A►eay L� <br /> Pit or Grout inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE (�A�M,�OU�N�T REMITTED CK CASH RECEIVED BY DATEPERMIT'NOt. <br /> +.EH13.24IREV-r/H51 3 I NL ,fL [Q �p �1-A2311 <br /> EH 14-28 �/t <br />