88-981 - Laserfiche WebLink

Home Browse Search

I p --(, UG APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) "F 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 N 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 4865 East Woodbridge Rd C;ryAcampo Lot Size 20 acres PM Owner's Name George Floyd 4 Address Same Phone 334-5265 Contractor's Name C lark Well License No. 371560 Phone 462-7676 . TYPE OF WELL/PUMP: NEW WELL .❑ WELL REPLACEMENT CS DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK}1 5_0V SEWER LINES DISPOSAL FLD. PROP, LINE 15 ' FOUNDATION AGRICULTURE WELL�"1 000 'OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation 11 Dia. of Well Casing 12 3 4 ❑ Domestic/Private gkGravel Pack ❑ Tracy Type of Casing Steel Specifications . 188 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 2 3 5 f1 Type of Grout j $1 Irrigation 9 —Approx. Depth C1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done NA EI Destruction Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within2004eet.) Installation will serve: Residence— Commercial Other Number of living.'uhits:j, P !.Number of bedrooms .3171E } . 4 .y 6 5 j Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK C LEI Type/Mfg' ('Capacity No. Compartments r, " .r '! ~ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines E' Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i 2 SEEPAGE PITS ❑ Depth Size Number SUMPS 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, 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 that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion Eaws of Cal'ornia." The applican cal r a I r re m ns. Complete drawing on reverse side. I Signed Title: tVP-Clark Well Date: 2.1 'Apr i 1 88 1 ' FOR DEPARTMENT USE ONLY c ' ` Application Accepted byDate 4101160 Area &1 i Pit or Grout Inspection by• �� Date �� Final Inspection by Date Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 J Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ` FEE gMOUNT DUE AMOUNT REMITTED CK# INFO RECEIVED BY DATE PERMIT"NO, I! CASH +EH 14-26)RSV.1!1!831 jr- EH ! a` 10 'Y+�� !�Q �Or 76 f