86-1354 - 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 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. Job Address 2444 Cast Lathrop Rd Lathrop P Lot Size 20 acres PM Owner's Name Con Fab PO Box 1369 Address Phone 858-2527 Contractor Clark Well Address 2024 E. Charter371560 462-7676 License Na. Phone TYPE OF WELL/PUMP: NEW WELL.RIx WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION gyp( SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /Ann 1 SEWER LINES DISPOSAL FLD. ROP. LINE _. 12[7 1 r FOUNDATION AGRICULTURE WELL OTHER WELL PI S/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation 1 �j ia. of Well Ca g �S ❑ Domes#ic/Private IN Gravel Pack ❑ Tracy Type of Casing S tee1 Specifications 2 C Public ❑ Other ❑ Delta Depth of Grout Seal 9 S a k ❑ Irrigation Type of Grout g ---Approx. Depth ❑ Eastern Surface Seal Installed r k Repair Work Done ❑. Type of Pump Sub H P 5 I n s t a 11 St Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ 1N septic system permitted if public sewer is Installation will serve: Residence— Commercial— Other available within 200 feet.) rr Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE El No. & Length of lines Total length/sizeOL FILTER BED E3 Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line 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, an rules and regulations of the San Joaquin 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 to become subject to workman's compensation laws of'California."Contractor's hiring or sub-contracting signature certifies the following: "I certify th rformance of the ork for which this permit is issued,I shall employ tion laws of California." P Y Persons subject to workman's compensa- The applican c It r I r d cti amp drawing on reverse side. Signed Title; ark Well Data: 23 O c t 1986 (� 7 FOR DEPA TMENT USE ONLY Application Accepted by Date /10 IZ3 Area 13 Pit or Grout Inspection by Date!—� Final In ation by Date "C �> Additional Comments: CSS /_/jyi ifl ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82317`1--04 IJ Tracy 835-6385 J �7 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY l DATE PERMIT NO. - + EH 13-24(REV.) 8 s) la 5 r O� ,�1 5 EH 1428 3` t3 1