86-1569 - Laserfiche WebLink

Home Browse Search

F _�, APPLICATION FOR PERMIT ,.� , i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1Complete in Triplicate) k 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.".' r, ,y w Job Address 8715'-West' Grant, Line 'Road Tragi Lot Lot Size PM ..-. air t uite 300 -- r c/o Kaprael.ianM Engi.ne�aarrog= Martinez , CA 94553 Phone 4 6 228-1882 Owner's Name - Explorat.ion.. Geoservices San Jose, CA (9 -4 201 Contractor TnC Address License No.�,$ $ 'Phone TYPE OF WELL/PUMP: NEW WELL RX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE } „.FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �„� - k INTENDED USE S TYPE OF WELL 'Q; PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casin ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation t'' g CX Domestic/..Private IXI Gravel Pack ❑ Tracy Type of Casing PVC t Specifications ❑ Public Other M1.Onrt.OT❑ Datta Depth of Grout Seal min• Type of Grout Concrete roxDepth ❑ Eastern Surface Seal Installed by . Contractor ❑ Irrigation ��-.��p Repair Work Done El Type of Pump - H•R• — — State Work Done Ul f Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INS LLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ av0 septic system m permitted if public sewer is I Installation will serve: Residence{ mercial Other Number of living units: Number of be ooms Water table depth Character of soil to a depth of 3 feet: _Type/Mfg pac�ity_ No. Compartments SEPTIC TANK ❑ ❑ Method of Disposal PKG. TREATMENT PLT. Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total.length/size FILTER BED ❑ Distance to nearest: all. Foundation Pro�Line- _ a ' SEEPAGE PITS :1 Depth Size — Number t SUMPS ❑• Distance to arest: Well Foun ion Property Line DISPOSAL PONDS ❑ 4-hereby certify-that-1-have-prepared-this applicationand that=tFie_�nrork�willb e`done-inta wa^ce=with-San Joaquin county-ordinances;st8t nd rules and regulations of the San Joaquin Local Health District. Home owner or license"gent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not j 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 ornia." i The apl l nt mus all for all r fired ins ctions. Complete drawing on reverse side. Title: Engineering Geologist Date: .5/2 /86 Signed s FOR DEPARTMENT USE ONLY I Date 77:- Area Application Accepte y ( Date �6 Final Inspection by Date>_�_4°l � k Pit or Grout Inspection by Additional Comments: Q Stk 466-6781 ❑ Lodi 369-3621 CI Manteca 823- ❑Tracy 835 Bpi �O��G osd�wT Applicant- Return all copies to: Environm nto Health�it/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201�� r FEE AMOUNT DUE' AMOUNT REMITTED CASH - RECEIVED BY -DATE PERMIT"NO. INFO + EH13241REV.7/B51 ¢ -4Si.,J ` 5. � �_S �a �EH 1428 -. 0-i An