FIELD DOCUMENTS_CASE 1 - Laserfiche WebLink

Home Browse Search

-.,..P ' ' t PLICATION FOR PERMIT r UIN LOCAL HEALTH DISTRIG3 KAPREALIAN ENGINEERING, INC. AZELTON AVE., STOCKTON, CA Consulting Engineers elephone (209) 466-6781 IRES 1 YEAR FROM MATE ISSUED 535 MAIN STREET .1 MARTINEZ,CA 94553 (Complete in Triplicate) (415)372.5444 istrict for a permit to construct and/or install the Alhere described. his appficat is for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Locat Hearin urstrrct. , Job Address 1 Y�L 64 • City Lot Size PM Owner's Name /r t Q iI , Q! / `O - Address P 0• &A Z.7- 7 �f 'Ch�*i AdPh,na c+�,J05e- I Contractor exp&& fti)5c Ir Address , License No.� Phone ` TYPE OF WELL/PUMP: NEW WELL)'-4N ~5 --WELL REPLACEMENT ❑ DESTRUCTION ❑ M L,)e 115 PUMP INSTALLATION ❑ Mk)i5 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j L � i ❑ Industrial LD Open Bottom ❑ Manteca Dia. of Well Excavation 0 Dia. of Well Casing Domestic/Private +Gravel Pack XTracy Type of Casing—M AS1rt 1 Z&s Specifications 6.62,0" 5/0t ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _ode Type of Grout t ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION O DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) i 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 CapacityNo. 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 C Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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." I The applicant must call for all reg fired inspections. Complete drawing on reverse side. C see a ifuL hed Title: Date: �/`- /8 Signed X — " ' ' ! =Aiff Y l � Application Accepted by — n!ttDate ea Pit or Grout Inspec '�tf�ate Final Inspection by Date �2 Additional Comments: r ❑ Stk;466-6781 ❑ Lodi 369-3621 ❑ niece 823-7104 ❑ Tracy 1 f / Itr9L Applicant Retum'alhcopies to:'Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. ox 2008, Sttk„ C 1 FEE AMOUNT DUE AMOUNT REMITTED C 5� RECEIVED BY DATE PERMIT'NO. INFO • EH 14-24 TREY. •R��1 _�,��S. C.L I AIA 1 ��1� 7 �7 EH 1428 �'V t. - - -