Laserfiche WebLink
t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I - <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein de n is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulatio S Jo in <br /> Local Health District, <br /> Job Address ­City StOCktOn Lot Size 1401 x160 t PM <br /> Owners Name Saitr}T1and Corp_ Address 5820 Stoneridge Mall Rd.PleasanVwhe 415 463-2711 <br /> Contractor Address5Q47Clayton Rd. License No. 3_rf- 3 Phone S 671-23 7 <br /> TYPE OF WELL/PUMP: NEW WELL CR WELL REPLACEMENT ❑ DESTRUCTION D <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR I—) OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 7 DISPOSAL FLD. ? PROP. LINE 10 ft. - <br /> FOUNDATION 15 ft. AGRICULTURE WELL ?OO ftQTHER WELL 300 t•PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial 1.1 Open Bottom Ll Manteca Dia. of Well Excavation__$_in, Dia. of Well Casing <br /> [X Domestic/Private (}R Gravel Pack ❑ Tracy Type of Casing_W-C Specifications .020 in. <br /> I'1 Public n Other n Delta Depth of Grout Seal _]O_ .� ung_ Type of Grout <br /> I.I Irrigation 55ftppprox. Depth i1 Eastern Surface Seal Installed by-Sl0rrs`l Pacific Dr>_lliLig _ <br /> Repair Work Done ID Type of Pump _ H.P. State,Work Done <br /> Well Destruction 1'i Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> i <br /> j TYPE OF SEPTIC WORK: NEW INSTALLATION Il REPAIR/ADDITION 11 DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Y_____ Other _ <br /> Number of living units: - Number of bedrooms <br /> Character of soil to a depth of 3 feet: .--------Water table depth <br /> i <br /> SEPTIC TANK [ I Type/Mfg capacity-- � No. Compartments _ <br /> i PKG. TREATMENT PLT. I I Method of Disposal <br /> Distance to nearest: Well .__ Foundation- _ Property Line <br /> LEACHING LINE I I No. & Length of lines Total length/size— <br /> FILTER BED Ll Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size �• Number <br /> SUMPS I I Distance to nearest: Well Foundation . _. .__. Property Line <br /> DISPOSAL PONDS I I <br /> 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 <br /> rules and regulations of the San Joaquin Local Health District. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> r 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- <br /> tion laws of California." <br /> Tho <br /> _111 drowing un nrverw side, <br /> Signad X '�L�`��'t u.— c Title: PYc)jg orf- Ge01()a1Sit Date: A-21—R(-, <br /> F P T NLY <br /> Application Accepte4by Date ' :eg Area <br /> Pit or Grout Inspectfinal Inspection by_—:�%r rAdditional Commen <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.. P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> �. EH 13-24(REV.I i n Til <br /> EH 14-28 <br /> liaew tiI, <br /> EH 08 05 II <br />