89-2616 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT it SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781Mp�� { �PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4• (Complete in Triplicate) OC, Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein d<F*s3ASSis 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. G'0/jR01VMENTAL HEALTH Job Address 205 E• Moffat city Manteca Lot Size SCR VNT/SERV1cE5 PM ( 415) Owner's Name Golden Grain Addressl 1 1 1 i 39th_ Aizv , San LeandrGhone 179 — 1401 Halyard Dr. , Ste. 140 C57 ( 916) ContractorGroundwater Tech. Address West Sacramento License No. 43434,3 Phone 372-4700 TYPE OF WELL/PUMP: NEW WELD WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK -- SEWER LINES DISPOSAL FLD. -- PROP. LINE _51-- FOUNDATION 6Q ' AGRICULTURE WELL -- OTHER WELL — PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 7 �5 Dia. of Well Casing 11 ❑ Domestic/Private 91 Gravel Pack ❑ Tracy Type of Casing PVC Specifications sand/ M Public F1 Other F1 Delta Depth of Grout Seal aType of Groutceme g I I Irrigation 5V.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION E I DESTRUCTION I I Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth v SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f` PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i 1 Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C7 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, 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 worensa- tion laws of California." SAN )OAQUIN LOCAL HEALTH The applicant m st call for all required inspections. Complete drawing on reverse side. ENVIRONMENTAL HEALTHH DIVISION Signed x Title: Geologist §pECiA�a�ER1� T3/89 (,,, FOR DEPARTMENT USE ONLY / (7 Application Accepted by Tt' Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 0 Lodi 359-3621 ❑ Manteca 623-7104 ❑ 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 R�cE,MMIITTED CK 1 RECEIVED BY DATEi� �/PERMIT NO. + EH13-24MEV.1/05) 35�`�+ 5, v� ba� �•��pmt O / a�t� EH t4-26 /