85-1141 - Laserfiche WebLink

Home Browse Search

ms's APPLICATION.IFOi,PERMIT . SAN JOAQUIN;LOCAL HEALTH'. DISTRICT 1601 E. .HAZEL T ON.AVE., STOCkTON, CA ! �' J 1 I 2 4 Telephone (209)_46&6181' ../ <e x"«� r,, = t i rr � z s ar.�t+� �+Ie ir3` r2 u:r; ,,x ." �ry^�'u• i L 6T PERMIT EXPIRES,1 YEAWFROM BATE ISSUED .i4 •,, ,.,,'�,.C, .<' Ejl;at ikr �Q-:�/, �f�gSe�iri cY.s Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desGribed.,7Ns application is made imcompliance;with-San Joaquin County,Ordinange No._549;fo-r;sewageior.No.-1862 for well/pump and the Rules and Regulatiohs'of the SanJoaquin Local Health District. '•t::.a r1tlZ# ?:7 S✓ q.S :)e . flo t„ J,7 f trr' .•� is Job Address Lo#!Size •' PM E ' � k " wmi is Name �-- Address Phone '- t. ' `Name Lic No. - _ Phoned—f1,7 TYPE OFWELL/PUMP:, NEW WE L L,-9, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION f ,;. SYSTEM REPAIR ❑ r OTHER ❑ ��-, �� DISTANCE-Tp NEAREST: SEPTIC TANK SEWER LINES � DISPOSAL FLD. L� PROP. LINE ` l FOUNDATION AGRICULTURE WELL OTHER WELL , — PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS'; �i L1 Industrial *Pon Bottom 171 Manteca. Dia. of Well Excavation �� _ Dia. of Well Casing ;;540mestic/Private El Gravel Pack ❑ Tracy Type of Casing �� ,c� ^ Specifications 11 Public ❑ Other `❑ Delta Depth of Grout Se1fi Type of Grout ❑ Irrigation ----4pprox, Depth ❑ Eastern Surface Seal Installed by t Repair Work Done ❑ Type of,Pum' H.P. Stlate Work Done ! � Well Destruction D ' Well Diameter Sealing Material (top 50') r -Depth Filler Material IBelow 501 ,TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONI❑ (No septic system permitted if public sewer is J . - V .... ... . I . . . I - ry "! available within 200 feet.) tW7 r Installation will serve: Residence Commercial'_' Other Number of living 'units: Number of bedroom's 4 j .r t Character of soil to a depth of 3'feet: Water table depth Z SEPTIC TANK ❑ Type/MfgCapacity No. Compartments ' PKG. TREATMENT.PLT,71 �! `° � Method of Disposal Distance to nearest: Well Foundation *"Property Line LEACHING LINE E ❑ .No. & Length of lines Totaliengthlsize 3 FILTER SED ❑ Distance to nearest_ Well Foundation i, Property Line SEEPAGE PITS ❑ Depth i -Size Number 'SUMPS i-❑ "Distance to nearest: 'Well,- —".Foundation Property Line ' i 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 c rules and regulatioris of the San Joaquin Local Health District. r •?- --`- .- d. Horne 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 M. employ any person in such manner;as to become subjedt-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. The applicant ust call for all requ' inspections. Complete drawing on reverse side. , Signed X x � Title: Jets t ty7�i.� i- Date: fFOR DEPARTfiA NT USE ONLY _ Application Accepted by. �'v Date L Area C o Gro Inspection by "v date! Final inspection by Date —�� v ' 'Y Additional Comments: a❑ Stk -466-6781._'- odi- 369-3621 - -❑-Manteca 823-7104 F (]Tracy 835-6385 Applicant- Return all spies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 q 3 j INFO aAMOUNT UE AMOUNT REMITTED SW t RECEIVED BY.h DATE G.. PERMIT'NO. + EH 13.24{REV. EH 1428