87-495 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. APN-199-390-�'67 Job Address �. 8"z1�. Prescott City-Maiate_CA Lot Size PM Owner's Name Mitch Salai7, Address 15 811Prescott Phone Contractor Clark Well Address202East -CharterWavuicense No. TYPE OF WELL/PUMP: NEW WELL 3'71 5h� Phone4-62-7 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONNX SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK +12 T SEWER LINES FOUNDATION AGRICULTURE WELL OTHER SWELL 2 A t AL FLD. PROP. LINE O' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Xk1Manteca Dia. of Well Excavation rr Xl�omestic/Private Dia. of Well Casing n XXGravel Pack ❑ Tracy Type of Casing-S te z 1 El Public ❑ Other C1 Delta Specifications �1 2 Depth of Grout Seal � Type of Grou ❑ Irrigation —Approx. Depth C1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump __, tth H.P. State Work Done Well Destruction ❑ Well Diame r Sealing Material (top 501) Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIWADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence— Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ T Water table depth Type/Mfg PKG. TREATMENT PLT. ❑ Capacity No. Compartments 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 ❑ Depth Size SUMPS ❑ Distance to nearest: Well Foundation Number DISPOSAL PONDS ❑ Property Line 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 certifies the following: "I certify that in the performance of the work for whichipelaws ss California."Contractors hiring c sub contracting signature tion laws of California." permit is issued,I shall employ persons subject to workman's compensa The applican cal or ui d ' s. mp a drawing on reverse side. Signed Title: VP- Clark Well & Equip Date: 4 March 1887 FOR DEPARTMENT USE ONLY Application Accepted by Date tWL.Area Pit or Grout Inspection byJ Date�' Fina! Inspection byp'7 Date��O / 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 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT NO. + EH 3.24 1IREV.1/9 5) EH 428 1 c:,