89-563 - Laserfiche WebLink

Home Browse Search

.?�. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E. HAZEL i 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. oaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 15 . .r R_t� .- Corner of 4"Quashnick & Oakwi lde(to be built) '�� (a30P 3S Job Address '.o5 :mile east- HWy 99.'_`Qn 7-Qua.shhir_.k City Lot Size � • 5 acre PM Owner's Name ZaQariS Manaclemeni- Address 1.230 E Oranwabil a Modesto Phone Contractor Clark Well], Address2024 E Charter Way License No. 371 560 Phone 452-7675 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER i0k Test Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.1 PROP. LINE -2r. r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS1.r�nr ( N INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS „vet 8" Te Well to 300 fl Industrial ❑ Open Bottom 1-1 Manteca Dia. of Well Excavation Dia. of el! asrng ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Public (7 Other n Delta Depth of Grout Seal Type of Grout , h� I Irrigation —.-Approx. Depth 1 I Eastern Surface Seal Installed by •f Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material IBelow 50') , TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is r I 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 ❑ TypelMfg Capacity No. Compartments j 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 I SEEPAGE PITS I I Depth Size Number SUMPS ❑ 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, statelawsana rules and regulations of the San Joaquin Local Health District. , Home owner or licensed agent's signature certifies the fotlowing: "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: " ify 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 Wrni "The applicanII uire nspections. Complete drawing on reverse side. Signed Title: VP Clark Well Date: 21 Mar 89 FOR DEPARTMENT USE ONLY p Application Accepted by Date Z o Area Pit or Grout Inspection by Date Final Inspection by Date 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. Hazetton Ave., P.O. Box 2009, Stk., CA 95201 INEp AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT ND. ♦ EH13-24tREV.iiHsl I?+^ EH 14 25 f