88-2997 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON 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. Lot of Record Job Address 4754 E. Woodbridge Rd city Acampo Lot Size PM Owner's Name Gordon & Vickie KOSt Address same Phone x..3.4--4106 ContractorClark Well Address 2024 E. Charter License no.371560 Phone462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION [RX PUMP INSTALLATIOr9Cic SYSTEM REPAIR ❑ OTHER ❑ 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 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications fl Public (I Other F Delta Depth of Grout Seal Type of Grout I I Irrigation .Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done k3X Type of Pump sub H.P. 1 i /:;, State Work Done _ install C� Well Destruction Ek Well Diameter '�1 Sealing Material (top 50'1 9 , Depth na Filler Material (Below 50') rr rr TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I l 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 t Character of soil to a depth of 3 feet: Water table depth i 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 1 Depth Size _� Number SUMPS 0 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: "!cert) 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 Californi The applican s all r d i ns. mpl a drawing on reverse side. Signed X Title: VP Clark Well Data: 8 Nov 88 FO EPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection byDate .,Final Inspection by 14 Date z34 -�` Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMn'NO. ; EH 13-24(REV.t/n5) EH 14-211 '0 Q G f O��[t1c7 1 UV r U r -7/}, Y1