89-443 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA FEB 2 gin: a,0C J 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. 2.0 mile West Bacon Island Road& Highway 4 Job Address City f f t Lot Size +50 a r.Y e C PM Owner's Name Conrad Silva Address 3211 S_ Holt Rd 1-1 r) Phone465-1834 Contractor Clark Well Address 2024 E. Charter License No371 560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT P9X DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK1 50 r SEWER LINES DISPOSAL FLD. PROP. LINE'7_5_L__ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing 6 5 18 rr X® Domestic/Private JrkrGravel Pack ❑ Tracy Type of Casing PVC Specifications SCH 40 ('l Public F1 Otherr _ x9�elta Depth of Grout Seal 30 Type of Grout Bentonite I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Clark Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I 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 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 LINE ❑ No. & Length of lines Total length/size �J FILTER BED ❑ Distance to nearest: Well — Foundation Property Line �F^ SEEPAGE PITS I I Depth Size _ Number SUMPS Cl Distance to nearest: Well_ Foundation Property Line DISPOSAL PONDS ❑ 1 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 Diltrict. 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 certif that in the performa a of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant t or Il qui s ion Complete drawing on reverse side. Signed X Title: VP Clark Well Da43 Feb 1989 FOR DEPARTMENT USE ONLY ��j q Application Accepted by --- - -- Date n t Area Pit or Grout Inspectio y an�te Fin nspection by - / Y Date Additional Comments- �0.XX. , O Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823 04 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., A 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. Z3 + +.EEH H 13-24 24(REV.t/e 5) T �;ItJ 3C3g —�43