86-1345 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) _application the work Application is hereby made to the San Joaquin rLocal ca Hece lth District5 for sewage or permit to 1862 cfor onstruct and/or n/pump and he Rules and'Regu�lations of the San Joaquin made in compliance.with San Joaquin County Local Health District. 2 0 Acres 6950 Hogan Rd city Lodi Lot Size PM Job Address 3 6 8 '5 0 35 frank FaSSi 6951) LHogan -- Phone AddressOwner's Name 37156'3 462-76762024 E. ChWay Phone Clark Well Address License No.�-- 2 Contractor WELL REPLACEMENT 91 DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑. OTHER ❑ PUMP INSTALLATION X SYSTEM REPAIR ❑ }200' t SEWER LINES �— DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK — AGRICULTURE WELL 00'OTHER WELL PITSISUMPS FOUNDATION �� TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS 10 3/4 r INTENDED USE pia. of Well Excavation Dia. of Well Casin ❑ Open Bottom El Manteca S t e l3 ❑ Industrial Type of Casing Specifications ❑ Domestic/Private � Gravel Pack ❑ Tracy Yp N A Type-of Grout ❑ Other ❑ Delta Depth of Grout Seal E ar ❑ Public .., Surface Seal Installed by a' f Irrigation --Approx. Depth ❑ Eastern ng a Sub H.P. State Work Done Repair Work Done ❑ Type of Pump Sealing Material (top 50'1 Well Destruction {❑ Well Diameter Filler Material (Below-501 Depth HYPE OF SEPTIC WORK: NEW INSTALLATION d REPAIR/ADDITION ❑ DESTRUCTION ❑ aaailablelw t in 20c system 0 feet led if public sewer is �, Installation will serve: Residence Commercial, Other Number of living units: Number of`bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity— No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Line Distance to nearest: Well Foundation Property ' Total length/size LEACHING LINE CJNo. & Length of lines property Line FILTER BED ❑ Distance to nearest: Well Foundation SEEPAGE PITS ❑ Depth Size Number SUMPS ClDistance 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, state laws, and rules and regulations of the San Joaquin Local Health certify that in the h District. not Home owner or licensed agent's si n rtifies the following: "1 performance of the work for which this permit is issued, 1 shat signature employ any person in such man r as to beco subject of to workman's ora for which compensation ionPerit issueof d,I shall employ personslsubject t workman'ring or s aompensa- certifies the following:"I certify t at" the pe tion laws of Cali rni ." The applican 11 fo all u' in ctio drawing on reverse side. 21 4 C t 1986 me: Vp—Clark Wall Date: Signed t x OR DEPARTMENT E ONLY Date � ' J� Area Application Accepted by mal Inspection by pa'e Pit or Grout Inspection by 411/ Additional Comments: ❑ Manteca 623-7104 ❑ Tracy 835-6385 ❑ 5tk 466-6761 ❑ Lodi 369-3621 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED BY DATE PERMIT NO. IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH ,Cr + EH 13-24(REV.1/s 5) EH 14-26