90-460 - Laserfiche WebLink

Home Browse Search

. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA gvso i Telephone (209) 466-6781 199 PERMIT EXPIRES 1YEAR FROM DATE ISSUED t �R fL�NY fComplete in Triplicate) S1 ��A svvlc� PU�1.IC ��p,a#!��a1Vt�t04 t iApplication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the RI60-ke'd. 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. 42 e " Y ff Job Address ha.rpP Armor 1)P.T)ot City Lathrop = Lot Size 800 AC PM 11 Owner's Name Lyon CO-MITIul'IftZeSAddress 2707 E Fremont ( S i OCkt0n)Phone 209-4,67-1561- ,! P.O.. Box 108 ( 96021) Inorth Valle Drilla ss Inc. Contractor � �' (,r Orn],.T>,a, Ca.l.License No. 4l SS'i-Z- Phone 6-824— 0 2 [;TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ � PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER L9 Monitoring 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 0 Manteca Dia. of Well Excavation _1 Q tr Dia. of Well Casing 411 '❑ Domestic/Private T7 Gravel Pack ❑ Tracy Type of Casing_4Q., -PVC.. Specifications l-1 Public (7 Other 1.1 Delta Depth of Grout Seal 1,9.7i n13 S Type of Grout 1k - -F. �Prr t 41 Irrigation V -3�:'Approx. Depth l I Eastern Surface Seal Installed by CeMP11L _ f .Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction LIWell Diameter Sealing Material (top 50'I mTonitoring Depth Filler Material (Below 50'1 _ 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION I I DESTRUCTION I ] iNo septic system permitted it public sewer is Q� 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 CIType/Mfg Capacity No. Compartments PKG. ` TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Wel( Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size :FILTER BED ❑ Distance to nearest: Well Foundation Property Line L . t SEEPAGE PITS t I Depth Size Number f "SUMPS ❑ Distance to nearest: Well FoundationProperty Line (DISPOSAL PONDS ❑ 11 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- ',6n laws of California." EThe applic t ust call for all re it inspections. Complete drawing on r e side. Signed X Title: nate: FOR DTfVIENT S Y � !Application Accepted by Date �� it or Grout Inspection by Date inai Inspection Date f r: Additional Comments: k ❑ 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 k FEE INFO AMOUNT DUE AMOUNT REMITTED twsn CK RECEIVED BY DATE P£RMIT'NO. +.EHU-24(REV.tiN5) � UE] �. UID —S`-'r7/� �D`y k) EH 14-26 Z7�J�Lp ttJJ r