87-471 - Laserfiche WebLink

Home Browse Search

5 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ,E t' 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -' -7, {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 Wealtfi District.' r � 1 Job Address 98800 gi i,er go;a l _ City Fsc2lan Lot Size 5 Arre __ PM Owner's Name gheS'eter N. Daniel { .._ Address 2404 N.__Santa Fe Ave. , � Phone _(.209)523-1682 Modesto; CA 95355 r. Contractor Chet Daniel Con stuct=Adod in 2044-R_ Santa_Fe_Ave.,_�-'.L celse,N;��4'16401- ,Phone..523-1682 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO T: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE TION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL OBLEM AREA CONSTRUCTION SPECIFICATIONS E ❑ Industrial # ❑ Open Bottom ❑ Man Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Casing Specifications ❑ Public + . ❑ Other ❑ Delta Depth of Gro I Type of Grout f ❑ irrigationf� �Approx, Depth ❑ Eastern Surface Seal Installed by ! O Repair Work Done ❑ Type of Pump H.P. State Work Don y t O Well Destruction ❑ Well Diameter .Sealing-Material (top SO') I - Depth Filler,Material [Below-,501 It� NA TYPE OF SEPTIC WORK: -NEW INSTALLATIC$4 C1.1 R AIR/ADDITION O" DESTRUCTION Ll (No septic system permitted if public sewer is lft I `►;A} available within 200 feet.l { Installation will serve: Residence Commercial 10ther Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: sandy lg8l , Water table depth SEPTIC TANK" 4 Type/Mfg's Capacityani,No. Compartments " PKG. TREATMENT PLT. ❑ Method of Disposal leacb line ' Distance to nearest: Well. .1.1 25'ft Foundation 25 ft Property Line 17S ft LEACHING LINE ' No. & Length of lines i r rpa Total length/size r '1 1 FILTER BED ❑ Distance to nearest: € Well,11 32' Foundation— 381 Property Line 130 r I P. SEEPAGE PITS ❑ Depth I ` Size, Number SUMPS ❑' Distance to nearest: t Wd Foundation Property Line__.__ DISPOSAL PONDS ❑ t I hereby certify that 1 have prepared this application and that the ork 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 applican ustIl f all requir d nspections. Complete drawing on reverse side. . { i i III Signed Title: �,rnnr Date: March 9-1987 FOR= EPAfiTMEPiT USE ONLY "^ /� i Application Accepted by Date Area v`9 /S Q Pit or Grout Inspection by / E Date Final Inspection by Date 4 Additional Comments: ` � C'� ' ¢ U��l�eZ� tCeWlf ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED # RECEIVED BY DATE PERMIT''N0. + EH11428 3-24 PREY. EH 1/95) {J� �� '3 3r3/ JE`7�� r [!