SU0003384 - 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 , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DEC 12 19L'9 (Complete in Triplicate) ENVIRONMENTAL f lF AL.TI-1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the�yrp �Or 'Tfi @spry �d�rT�ii application is made in compliance with San Joaquin County Ordin�^c©No. 549 for se age or No. 1862 for well/pump and the u rltl'{1�hllrtl is of lx�San Joaquin Local Health istrjcyya/^d � e r' �/ Job Address 16777 Howland Road 7 �;ty Lathrop Lot Size PM Owner's Name J. R. Sim lot Company Address P.O. Box 198, Lathrop, CA 95330Phon, 2_09/858-2511 Moor-man's 2120 Wilcox Road Contractor Water Systems Address Stockton, CA 95205 License No. 468816 Phone 209/931-321 TYPE OF WELL/PUMP: NEW WELL 17 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER)1 OLA-* r��t2JUN'� 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 Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I') Public 1-1 Other Fl Delta Depth of Grout Seal Type of Grout I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by �-- Repair Work Done 13 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 501 .1 Depth Filler Material (Below 501 __ J TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Q Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Ll Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS 1-I Distance to nearest: Well 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, slate laws, and rules and regulations of the San Joaquin Local Health Di§trict. , 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 C n The appli n% tall r ui d ' late drawing on reverse side. Signed Title: Environmental Technician Data: 12/1118 FOR DEPARTMENT USE ONLY Application Accepted by /'/! � Date Area \ Pit or Grout Inspection by . Date � F��nspectipn by Datc��/ /C //``// Additional Comments: [7 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-71N ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT RE'M1ITTED C RECEIVED BY DATE PERM17 NO. . EH172�IREV.1inp1 /SO 't1� 150100 8151 -13-8� EH 14.2E 8`1— 3c-'O 7