FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA R E GE l V E Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED b 1�3C� i (Complete in Triplicate) r^,�p��LLAA A1 HgAL Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work tWRt:riti�Y r�alionon is made in compliance with San Joaquin County Ordinancu No. b49 for sewa0e or NO. 1662 fur welllpurnp and the Rules and Re�� rs �n Joaquin Local Health District. 3 33 LWT-W Lau o(t �#t 2 *ufiu� �� . Right of n r.r„ e._ _.._ Job Address =2.__ �^^+*��1aet}3�—n+ri:+rcft► City-_Lodi Lot Size Way PM Owner's Name Applied Geo Systems W Address 4191-E Power Inn Road, Sacramerti,@ne 916-452-2901 Contractor Spectrum Drill ing Address Isit:ane No. 512268 Phone 2_09-46S-87 I TYPE - - TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT CJ DESTRUCTION L-) PUMP INSTALLATION P SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK -- SEWER LINES 90' DISPOSAL FLD. -- PROP. LINE 20' FOUNDATION 50 r AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L] Industrial CJ Open Bottom 11 Manteca Dia. of Well Excavatio- n81 Dia. of Well Casing 211 I l Domestic/Private ❑ Gravel Pack I I Tracy Type of Casing SChd 40 PVC Specifications I'l Public f Other monitor I I Delta Depth of Grout Seal —AG' Type of Grout rieaC CE'iRenL r I I Irrigation 7C) Approx. Depth I i Edbturn Surface Seal Installed by Repair Work Done 11 Type of Pump _ H.P. _ State Work pone _2" _ + Well Destruction i.i Well Diameter Sealing Material trop 50'I Neat cement Depth 65' Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I Wo septic system permitted if public sewer is W available within 200 leet.l V� Installation will serve: Residence Commercial` Other Number of living units: Number of bedrooms 1 f Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ( I Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE H No. & Length of lines Total length/size f FILTER BED Ll Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS I I Depth Size Number y SUMPS I l Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 I hereby certify that I have prepared this application and that the wotk 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: r' "I certify that in the performance of the work for which this permit is issued, I shall not�j 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, tf lox fs' t work n¢ . nsi tion laws of California." r;l�� :,t,p1krp,?T.� !R.� to QEkFr1at�8, °rl'4t4 _ The applica must call for allrequired inspections. Complete drawing on reverse side. Signed x ` ,�--Barry Marcus Project GeologistTitle: J Date: m FOR DEPARTMENT USE ONLY I Application Accepted by Date J / Area y Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: LJ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-5385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO DATE PERMIT NO. 4 EH 14246{HEV,I/x e� `r.. � { S I,_� � ` y 11 1 �j -J.-�c�