FIELD DOCUMENTS FILE 1 - Laserfiche WebLink

Home Browse Search

` APPLICATION FOR PERMIT "or, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T 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 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 1403 Cotmtry Club Blvd. city Stockton Lot Size .92 acres PM Owner's Name Mobil Oil Corporation Address 3225 Gallows Rd. Fairfax, VA220 phone 818-953-2612 Contractor Target Environmental Addresg Columbia MD License No. n/a Phone301-992-6622 TYPE OF / 1 NEW WELL ❑ WELL REPLAeWPrfF ❑ DESTRUCTION C7 PUMP INSTALLATION ❑ SYSTEM REPAIR U OTHER Z11 see appendix 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE S_e_eappendix 2 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L) Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ll Domestic/Private U Gravel Pack U Tracy Type of Casing Specifications ('I Public ( I Other ❑ Delta Depth of Grout Seal Type of Grout I ! Irrigation -.__Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done L7 Type of Pump H.P. State Work Done_ Well Destruction U Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION ( 1 REPAIR/ADDITION I 1 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 U Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation- Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED [I Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS L I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS L 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 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 m st call for all reauirad inspections. Complete drawing on reverse side.�/ Signed X Title: Aeomcr Y•+k61G 6q, Date: ' Jt-Y ?G-, /`l8cc FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH r EH 13.24(REV. /H 5) EH 14-26