86-979 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT /� SAN JOAQUIN LOCAL HEALTH DISTRICT V 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. Job Address 12455 E. Atkinson Road City Lodi Lot Size 41-2 Acres pM Owner's Name Ted J. Spinelli Address Same Phone 209-931-4098 c� Contractor Self Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ( ^ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial 11 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONXr, DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence JL Commercial_ Other Number of living units: 1 Number of bedrooms 2 Character of soil to a depth of 3 feet: Clef =�(,J'7//� G' Water table depth 120 SEPTIC TANK XX Type/Mfg Concrete Capacity 1200 gal No. Compartments 2 PKG. TREATMENT PLT. ❑ Method of Di"l Dist�lce to nearest: Well 75' Foundation 10, Property Line 80 LEACHING LINE XX No. & Length of lines 1 Total length/size 50's t FILTER BED El Distance to nearest: Well 85' Foundation 15' Property Line 80 SEEPAGE PITS XX Depth 25' Size 33" Number 1 SUMPS ElDistance to nearest: Well 150' Foundation 100 r Property Line 30' 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, I shall not 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:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws Calif o 'a." The app'can us call for all req 'red i jictions.6omplete�drawing on rave ide./�X Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by ,,/ Date nw�(��'�Area Or r Grout Inspection by ate / ~ inal Inspection by •�°� I 00/ Date Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63% Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. INFO + EH 14.28(REV.1/95) a O' Com-- �{o_q-lQ