84-1289 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 0 C T Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED r SAN JOAQUIN LOCAL HEALTH DISTRICT, (Complete in Triplicate) a Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein de§cribed: 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�� I' Job Address 218 Mission Street City Lodi Lot Size R 1 a kP 1 Pa r k PM — Owner's Name Cit of Lodi Address Ca 1 1 Box 3606 �' Phone 6 Contractor's NamdCAL WATER DRILLING License No.434218 Phone6-3_2-jM TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT LJ DES I RUl i 1UN u PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑' DISTANCE TO NEAREST: SEPTIC TANK —"" SEWER LINES 150 ` DISPOSAL FLD. PROP. LINE 100 t FOUNDATION � 150, AGRICULTURE WELL --- OTHER WELL --- PITS/SUMPS INTENDED USE ❑ Industrial ❑ Domestic/ Private % Public ❑ Irrigation Repair Work Done ❑ Well Destruction ❑ TYPE OF WELL u Upen rsoaom M Gravel Pack ❑ Other 440k Approx. Depth Type of Pump Well Diameter Depth PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Manteca Dia. of Well Excavation 32" ❑ Tracy Type of Casing 5116 r-OlEtPri. ❑ Delta Depth of Grout Seal I 10' ❑ Eastern Surface Seal Installed by CALWATER,_ H P State Work Done _ Sealing Material Itop 50'1 Filler Material {Below 501 PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DES1 Installation will serve: Residence — Commercial Number of living units: Number, of bedrooms Character of soil to a depth of 3 feet: .1 SEPTIC TANK ❑ Type/Mfg I PKG. TREATMENT PLT. ❑ I Distance to nearest. Well ,l Other Dia. of Well Casing Specifications Type of Grout sack c system permitted it public sewer is within 200 feet.) Water table depth _ Capacity No. Compartments Method of Disposal Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth I Size Number SE - -sum PS—` `� _ ❑ Distance tolnearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 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, 1 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 California." � f The ap licant must call for all r ired inspections. Complete drawing o/n�raverse side. Signed Title:�_� r �� - Date: O Z F I-� FOR EPARTMENT USE ONLY O Application Accepted by Date —. ��-�-�ry1�� }�� Area C� Pit or Grout Inspection by Date Final Inspection by T-nej ;(-Ll��- — Date .D r4 Additional Comments: ❑ Stk 466-5781 ❑ Lodi 369-3621 ❑ Manteca 7104 ❑ Tracy 835AS385 �Y J- f � ,it iv y Applicant - Return all copies to: Environme I Heaith Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 c -c -orifi S zip /ice"DAT� FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY INFO + EH 13-24 [REV. 101831 el , EH 1426 1 �Yr, j4 A T. PERMIT "NO.' 4^r}1. l x ��"