86-303 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT �� SAN JOAQUIr! N LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,�STOCKTON, CA V�[ 41ry -'Telephone (209) 466-6781 + v1 �u s { ' 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 descr"ibed. 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. - }x'tt' r.., ff> faa. Job Address 27381 81N• `B16 S 0111'Rd, �T .Gity�hOrn�OSi -Lot Size PM Owner's Name Sarah Goldman _ - Same -=— - �" Address PhoneT 7LF -2533 r I Edward J. Ambrogio Address 229-)-th St. , Galt ,C C �606 2 #> Contractor `�ftense No. Phone 7 —1531, l 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i S _ pecifications I F1 Public ❑ Other ❑ Delta " Depth of Grout Seal Type of Grout ❑ irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done concre to arnd 2 Cas n } Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 8 Slw al al & C1or 1Yi R; Depth Filler Material (Below 501 �o TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i available within 200 feet.► ..) Installation will serve: Residence_ Commercial�� Other Number of living units: Numberrof bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg A ° Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 11 ll r i Method of Disposal 1 i. Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑" No. & Lengh of lines ' 7 tTotal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ SEEPAGE PITS ❑ Depth ' Size Number LA- SUMPS t: ❑ Distance to nearest: _ Well Foundation Property tine LA 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.. ,o,,. Home owner or licensed agent's signature eeftifies 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 t 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_pf Cali ornia. „�/ , The applicant ust call for all reed ins ctions'Complete drawing on reverse side. Signed X"-'' �`' , Z ” Title:Cantractor Ed��r.J sAmbro z®ate: March 27 l6 FOR �RTMENIT US ONLY Application Accepted by Date rea Pit or Grout Inspection by Date Final Inspection by Date_ Additional Comments: c L ' ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED, CK RECEIVED BY INFO CASH DATE PERMIT NO. + EH 1324 4REV. /w 51 - -r EH 1428I—