89-2591 - Laserfiche WebLink

Home Browse Search

.� T APPLICATION FOR PERMIT PAYMENT" - SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED f 1601 E. HAZE T ON AVE., STOCKTON, CA " Telephone (209).466-6781 SEP 19 1989 kPERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) _ -IRONMENTAL HEXLETH PEW khere( eSCri e Sr �- ApplicaEion is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here( escn a his application is i 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. >c ®�h��JIN LOCAL HEALTH DISTRICT 102 South Wi LS,on Way VINQ� MENTA. �IEALTH D1 Job Address _ Y city Stockton �iljS10N owner's Name Don Roek/Roek. Bros, Address P.O. Sox 30038 Stockton 95213 Phan,2(79/4b4—$344" Contractor PC ExpLoration Address 1780 Vernon St..* Ste:E LicenselNo.265556 Phone 916/783-973 i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Onit Of li3ct We PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 00 (2) 7r/i DISTANCE TO NEAREST: P I i SE T C TANK SEWER LINES DISPOSAL FLD. a PROP--LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS .! E) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i nChQS Dia. of Well Casing `7 E+ti Pack D Oomestic/Private L] Gravel Pack ❑ Tracy Type of CasingSChedu Le 40 PVC Specifications ('i Public A Other 2, M t S fl pelta Depth of Grout Seal �a� Type of Grout Cement I I Irrigation �_0 Appro r t. J � x. Depth I I Eastern Surface Seal Installed by r - Repair Work Done U Type of Pump NA H.P. NA State Work Done, Well Destruction © Well Diameter NA Sealing Material (top 50') W-e--V- tJ i Depth � � Filler Material )Below 50') _sand grave L pack N TYPE OF SEPTIC WORK: NEW INSTALLATION I,1 REPAIR/ADDITION I i DESTRUCTION I 1 1No septic system permitted if public sewer is 111 available within 200 feet.l f Installation will serve: Residence I Commercial_ Other vt 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 LINO ❑ No. & Length-of lines Total length/size FILTER BED C] Distance-'to nearest: Well Foundation Property Line 0 SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance'lo nearest: Well Foundation Property Line DISPOSAL PONDS E) 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 a p y an y 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 requirod inspections. Complete drawing on reverse side. 1 Signed Title t-/S Dat � FOR� SE ONLY ApplicatAccept:ed �v J��Date12a� Date / Area Pit or Grout Inspection by — Final inspection by Additional Comments: ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environlmental Health Permit/Services 1601 E. Hazolton Ave., P.O. Box 2009, Stk., CA 95201 FEE � I INFO AMOUNT DUE � AMOUNT REMITTED CK H FIECEIVED BY / DATE PERMIT"ND- a EH 13.241REV.I/M5) �$ 35 3S�(a EH 14 26 - " i