88-1422 - Laserfiche WebLink

Home Browse Search

t r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone {209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED z . f (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 j Local Health District. .2 miles north of Hwy 25 Job Address 720" West o .;Wall Rd. CityLinden Lot Size PM 1 Owner's Name Elizabeth Reid Address 5725 'Wall Rd. ,Linden Phone Contractor Purviance Dri ile]r'$r;�. F'.O.Box 64pLinden License No377923 Phone $87-3554 'TYPE OF WELL/PUMP:. NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION (Mp SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ;9 Open Bot'om ❑ Manteca Dia. of Well Excavation 12 Dia. of Well Casing 12 3/4 ❑ Domestic/Private ❑ Gravel Pack O Tracy-4' Type of Casing Steel Specification,X .188 Wal 4 S ❑ Public f.-f Other ❑ Delta%_ Depth of Grout Seal 0 Type of Grout— X rout _.XJ Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by _ r Now Repair Work Done E3 Type 40of Pump H.P. y � �'+State Work Done � __ j ow W.CA.r Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth r.. Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION I 1 DESTRUCTION l I Wo septic system permitted if public sewer is available within 200 feeL1 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 ❑ T ype/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ h 1. i Method of Disposal -. Distance to,nearest: Well 1 Foundation Property Line ,.LEACHING LlNEW ❑ No..& Length of line's I " # '' _ Total length/size -----FILT.ER BED-__ ,,_M a-Distance to nearest: 1/Uell "�Foundation s---- Property Line..__ f SEEPAGE PITS _ �'I-I Depth- ��. -Size Number i SUMPS LI Distance to nearest_ Well Foundation Property Line DISPOSAL PONDS t 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'Joaquih,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.fo become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that iii the Performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws'of California :Mj '" ri v The applic, ust call.4qf a r' ulred inspections. Complete drawing on reverse side. Signed X + ': Title: Pres]fent Date: 6/2/$8 F DEPARTMENT�USE ONLY Application Accepted by ff '1^^ Date i��✓� Area 2— Pit Pit or Grout Inspection by F Date al Inspection by Date f I- ! Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104° ❑ Tracy 83 5 Applicant - Return all copies to: Environmental Health PermitLSiarvices,1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 o :., FEE )NFO AMOUNT DUE AMOUNT REMITTED' O SH RECEIVED BY DATEW PERMIT NO. + EH13.24{REV.ii8si5r� �r