88-3274 - Laserfiche WebLink

Home Browse Search

APPLICATION ,FOR PERMIT �'S,,,Q_ JOAQUIN LOCAL HEALTH DISTRICT pgyry�ENT L� PLS p� 5kS kl E. HAZEL T ON AVE., STOCKTON, CA R EC E J V ED �OCPX AtS� Telephone (209) 466-6781 V1N 1pvPERMIT EXPIRES llYEAR FROM DATE ISSUED DEC 2ZCNNiC (Complete in Triplicate) NVIR TT�t Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo gr�� 9ALhiaA1§r*Jplication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the RuI ff911A 1I A4CES the San Joaquin Local Health District. Job Address 1220 F_ 1!I Gtnr pmaci _ _ cityLnd* Lot Size PM Owner's NameOyer-head Qbnr C-o _n- Addressl720 F_ Vi ctnr Fbad. I ojd CA Phone[ —4800 Sonoma Dr. C57# Contractor SK F euedi at an Address Ple-ac,anton CA License No 4.90 92 Phon( 0 1 TYPE OF WELL/PUMP: NEW WELLWELL REPLACEMENT ❑ DESTRUCTION ❑ ? PUMP INSTALLATION 0C1DtOr1rg8YSTEM 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 J� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation saw--at t ancd Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing mor-k i,I Specifications (l Public r(7 Othe�ee Dt.tDCMBelta Depth of Grout Seal Type of Grout _ I I Irrigation _AppHj*k0"l8n l 1 Eastern Surface Seal Installed by _ 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 11 REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0' Method of Disposal Distance to nearest: Well Foundation Property Line i I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well_ Foundation Property Line f SEEPAGE PITS l 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, 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�Cnalifornia."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issdtl N 40)koM"4!() AEb'tTAcL 4kp�r} gruppnsa- tion laws of California." ENVIRONMENTAL HEALTH DINMI CT The applica us call f at ed in ctions. Complete drawing on reverse side. � gECl/��. Signed Title: EMi heer•i ng aol oqi st. Date: �CAer 6, 1988 i SION FOR DEPARTMENT USE ONLY Application Accepted by Date Area I 1 �� s Pit or Grout Inspection by Data(L-�5 Final Inspection by Date A2"—Y_ y 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 96201 FEE INFO AMOUNT DUE AMOUNT REMIT/ED ASH RECEIVED BY DATE PERMIT NO. �( �� .. . +.EH13-14/HEV.r/Hs) EW 14-2e +� (