FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

+� • 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) 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. South of Job Address South Corral Hollow Road CityTracy Lot Size PM P. 0. Box 811 Owner's Name Connolly Ranch, Inc. Address Tracy, CA Phond209 835-7915 1780 Vernon St. (916) Contractor P. C. Exploration Address Roseville, CA 95678 License No.265556 Phone 783-9733 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ 1 Monitor well PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER f W-25N-07 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8Dia. of Well Casing3 to 4;" ❑ Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing PVC Specifications Cement— F] Public n Other 171 Delta Depth of Grout Seal — ]_3 f t tpe of Grout Bentonite__._ I I Irrigation 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 50'1 r Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 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 I Depth Size Number SUMPS LI 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, 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 workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: ®1'�c Gy Le oa&j Date: 6 'L3 —Y' FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection hv Date Final Inspection by Date Additional Comments: kl�� &_"_ l Amt nkrj — HI)0-zir, ❑ Stk 466-6781 ❑ Lodi 369-3621 1 ❑ anteca 823-7104 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 REMITTED H RECEIVED BY DATE PERMIT'NO. + EH13.24 IREV.I/H 51 EH 14-26 S. `'' 1 1 10