90-99 - Laserfiche WebLink

Home Browse Search

I y APPLICATION FOR PERMIT 'f SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON ON AVE., STOCKTON, CA RECEIVED E Telephone {209) 466-6781 JAN 11 1990 PERMIT EXPIRES 1•YEAR FROM DATE ISSUED SAN JOAQUIN WUNTY (Complete in Triplicate) NvPUUnBLII,C I1H�TEALTH SER1110ES it Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install�Mld`JGbYIC'�t:I WfAld E{L%AhIcation 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. Job Address 8976 V A L P I C O RD . City TRACY Lot Size PM k Owner's Name D O N L O S E Address P .O. BOX 326 TRACY Phone —LU-0422 Contractor NFMNTNt RRC1R_ T]RTI I i11 Address 2 5 2 5 R E I N D❑1 F ,t�%J P License No. 2 9 0813 Phone 545—1185 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ] DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1 D D t -1- SEWER LINES 100 t + 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 611 KI Domestic/Private )(Gravel Pack XIXTracy Type of Casing PVC Specifications ❑ Public f1 Other I F1 Delta Depth of Grout Seal 100 , Type of Grout—B-U10 M-1_.ZE- I Irrigation --Approx.l Depth l I Eastern Surface Seal Installed by R E N N I NGS, BROS . DRI I, ING { Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material /Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is favailable 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.r 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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS I I Depth Size Number L SUMPS CI 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: "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 required inspections. Complete drawing on a rse std, Signed X 7ifle: yUt Date: 1 —9- 9 0 F DEP TMENT USE ONLY i Application Accepted by Date ,Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: �O�l zl ❑ Stk 466-6781 C5 Lodi 369-3621 ❑ Manteca -7104 Tracy B35-6305 Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 r 1 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO +.EH13-24 IREV. EH 14-2a