88-2151 - Laserfiche WebLink

Home Browse Search

, U APPLICATION FOR PERMIT e ` SAN JOAQUIN LOCAL HEALTH DISTRICT pp►YMEH 1601 E. HAZEL T ON AVE., STOCKTON, CA R>ECE1 V ED Telephone (209) 466-6781 �� PERMIT EXPIRES TYEAR FROM DATE ISSUED AUG 19 x (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work C s application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rule s�eg�Eations of the San Joaquin Local Health District. =Y Job Address 27300 N.Sowels Rd City._,Aoampo Lot Size 10aC: PM 95A240 Owner's Name Bob Kent Address P.O. Box 1391 LOdi.Ca.. Phone 74 _4865 Ga1t,,C45632 Contractor Woods Well Br1f5xngddress 11944- Simmerhorn License No. 282 kf2 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION= SYSTEM REPAIR ❑ OTHER ❑ " DISTANCE TO NEAREST: SEPTIC TANK 3,50' SEWER LINES 1S0 DISPOSAL'FLD. 1 So PROP. LINE F+(1 t FOUNDATION 50 t AGRICULTURE WELL OTHER WELL PITS/SUMPS �~ INTENDED USE TYPE OF WELL'S PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑.Industrial }Open Bottom ❑ Manteca Dia. of Well Excavation _ ra wr Dia. of Well Casing $tt IQ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Steed. Specifications 1'1 Public ❑ Other Ll Delta Depth of Grout Seal so, Type of Grout sand.Ce117e 't I I Irrigation _-Approx. Depth• I I Easteln Surface Seal Installed by Woods Repair Work Done El- Type of Pump SubmerSllpl;E 3hp State Work Done Well Destruction ❑ Well Diameter Sealing Material stop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I DESTRUCTION l 1 (No septic system permitted if public sewer is O available within 200 feet.) J` r Installation will serve: Residence_ 'Commercial— Other" J Number of living units: Number of bedrooms 0) Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity - No. Compartments R r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line n V SEEPAGE PITS i I Depth Size Number ,SUMPS Ll Distance to nearest: Well 'Foundation Property Line -:i.-DISPOSAL.PONDS- =fl a 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 d 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 of California." E The applicant must call for al re fired, ins�ti�ons. Complete drawing on reverse side. / y Signed X -�Cf �� w Title: O`O>C1traC tOr Date: g/ g18S I FOA.DEPARTMENT USE ONLY Application Accepted by Date ~ Area Pit or Grout Inspection by Date inal Inspection by Date 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. Bax 2009, Stk., CA 95201 IEEE AMOUNT r DUE AMOUNT R,EEMIITTED CK RECEIVED 9Y D^�ATE PERMIT NO. + EH 13-24(REV.I/x5) l� ..�-�`—~ � QS, V�-3 ��(]1,. pt3�rSC1 ^-�� J�I EH 14-29 Ca'- 5 r: -