92-3765 - Laserfiche WebLink

Home Browse Search

f APPLICATION FOR PERMIT �� Yy s SAN JOAQUIN LOCAL HEALTH DISTRICT ..a 1601 E. HAZE T ON AVE., STOCKTON, CA � � Telephone (209) 466-6781 � � 6 � PERMIT•,EXPIRES ('YEAR FROM DATE ISSUED cl N 'iJO AQUIN C'C4,_tNTY -,,E (Complete in Triplicate) Yi� �i�, i^=�?;�I , �� 5 1��Fr4�,r J1!1i��111 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 r 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 I Local Health District. '3 '] /!v �. � T-3-N, R=6--E MDM Job Address ' City LO D T Lot Size PM Santa Fe Pacific= pipeline 888 So , Figueroa St , Los Angeles Owner's Name Address , pp Phone Glenn Martell & 5 � nc ,$tg181 ov'eri eC f _Contractor cA�ds:es � ��cense No, 510 9 5 2 Phon� 51 4 3 -- 8 2 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ - _ PUMP-INSTAL-L-AT.lON_D P ^� ., :SYST�M:fiEFA1R4U - _ GTHERAYi "Q i DISTANCE TO NEAREST: SEPTIC TANK �U�2 SEWER LINES X-A-n tDISPOSAL FLD Akife PROP. LINE FOUNDATION XsAGRICULTURE WELL 4� e OTHER WELL n°$ PITS/SUMPS 11�r.2 f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom- ❑ Manteca Dia. of Well Excavatioril4 t t o 5 0 r Dia. of Well Casing r' CK Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing F4 8 0 e Specifications M Public 0,Other - ❑ Delta Depth of Grout Seal f t Type of Grout 7ql a ck _ I t Irrigation 30 OApprox.-Depth 1 I Eastern Surface Seal Installed by slurry I Repair Work Done ❑ Type of Pump H.P. State Work Done_ -- i Well Destruction ;❑ Well Diameter 10 r' Sealing Material (top 50') Depth 3 0 0 1 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIRlADDITION LI DESTRUCTION I i (No septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT YLT. ❑ Method of Disposal 1 Distance to nearest: Well Foundation Property Line F LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 'r 6 °-- �' SEEPAGE-PITS" I-1—Depth = -51ze*'` " _ .Number-. SUMPS ❑ Distance to nearest: Well Foundation Property Line 1 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,SIZ and rules and regulations of the San Joaquin Local Health Di$trict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not i employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: '1 certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." The applicant must ruall for all r$ uired spections. Complete drawing on rr i se sde. / hh Signed)( �� Title: Q"7'►'1 C-e - At?11 Q of Date: I FO DEPARTMENT USE ONLY Application Accepted by Y Date2. Area_. If -� Pit or 4, t Inspection by . Date Final Inspection bye Date11 2 �2.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 INFO AMOUNT DUE AM UNT R MITTED t K H EIVED BY DATT. PERMIT NO. aEH13-241REV.1/K51W Ir D EH 14-26 !V 1- .J