89-2619 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA } ► Telephone {209) 466-6781 Ilt' PERMIT EXPIRES 1 YEAR FROM DATE ISSU41 3 I� (Complete in Triplicate} OCT N 19$g Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein de n �1 application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the � ' ,p the San Joaquin Local Health District. Vt �wq J Q �yI 1 p��N4lT!SOW p 1 I Job Address 2 11 6 S. Grant Ave. City_Manteca _. Lot Size PM 'Golden Grain! Co. ( 41 5) Owner's Name� 1f1�3 3��$3 .$ i�3 )f _ Address 1 1 1 1 1 3 9th A Ve- , q a n „I Pa nr7 Y fflnone — 61 72 j[ i 1401 Halyard Dr, , Ste. 140 ( 916) Contractor GrOUndwater TEeh,no4" r License No.C-57-4 34 3 one TYPE OF WELL/PUMP: NEW WELL ZI WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO�NEAREST: SEPTIC TANK -- SEWER LINES DISPOSAL FLD. -- PROP. LINE I� FOUNDATION 5 r AGRICULTURE WELL -- OTHER WELL -- PITS/SUMPS INTENDED 6SE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS XXlndustrial II ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationG" 7.-ter--.. Dia. of Well Casing 211 ❑ Domestic/Private 2 Gravel Pack ❑ Tracy Type of Casing plir SpecificationsCement� 1-1 Public 171Other t ,�. n Delta Depth of Grout Seal 8 ' Type of Grouts apf I I Irrigation 5Approx. Depth ! 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work pone Well Destruction ❑ Well Diameter Sealing Material (top 50') 1 c-� Il Depth Filler Material iBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION t I DESTRUCTION l I (No septic system permitted if public sewer is ' 1 available within 200 feet.! I ` 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 1 SEPTIC TANK I� ❑ Type/Mfg : CapacityNo. Compartments 1 PKG. TREATMENT PLT. ❑ " I Method of Disposal Distance to nearest: Well Foundation Property Line i I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED f ❑ Distance to noarest: Well Foundation Property Line w SEEPAGE PITS I I Depth Size Number - SUMPS Cl Distance to nearest: Well R Foundation Property Line 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, rules and regulations of the San Joaquin Local Health District. state laws, and 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." The applicant igned X Ik ist call for all required inspections. Complete drawing on reverse side. SAN JOAQUIN LOCAL HEALTH DISTRICT SGeologist HEALTH DIVISION Title: g i s t SPEC tpEIMT/8 9 FOR DEPARTMENT USE ONLY q Application Accated b -Z3, ,f z— p y Date ® v./ 6 fJ Area Pit or Grout Inspection by Date Final inspection byI3 1 Date_ =Z1 I Additional Comments: ' ❑ Stk 466-67811 ❑ Lodi 369-36211 ❑ Manteca -7104 F-1 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I� t f FEE AMOUNT DUE AMOUNT REMITTED INFO /�� n` CK��H++ RECEIVED BY DATE �} PERMIT'NO. �.EH14-24IREV.IiHs1 I 3S. L� 35, c5?.� 6�-J /0-a 4 EH U-2e I 1 li