89-519 - Laserfiche WebLink

Home Browse Search

APPLICATION FORi PERMITr. SAN JOAQUIN.LOCAL HEALTH- DISTRICT'' 16.01 E. HAZEL TON.AVE., .STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DA'L'E ISSUED (Complete in Triplicate) Application is heieby 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 1 545 S Holt Rd Cit Stkr1 Y Lot Size PM' Owner's Name Holt Union School DjA#,rjct same Phone Contractor C- lark Well Address 2024 East--Chartt--r License No. 37i _Phone 4F7_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ Q t - SYSTEM REPAIR ❑ OTHERy Test Well DISTANCE TO NEAREST: SEPTIC TANK -F 1 5V - SEWER LINES " DISPOSAL FLD. lPR`OP. LINE 2..5t FOUNDATION AGRICULTURE.WELL . OTHER WELL PITS/SUMPS INTENDED USE TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � ❑ Industrial Test Well 150 ' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing l ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F'i Public n Other i l Delta Depth of Grout Seal I I Irrigation Type of Grout g Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Weil Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I 1 DESTRUCTION i I (No septic system permitted if public sewer is i ` available within 200 feet.) Installation will serve: Residence— Commercial— Other r Number of living units: Number of bedrooms y f1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg t PKG. TREATMENT PLT. ❑ Capacity No. Compartments Method of Disposal Distance to nearest: Well Foundation property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BEDi ❑ Distance to nearest: Well Foundation Property Line � SEEPAGE PITS I I Depth Size Number SUMPS Cl 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 Di§trict. 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 44 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 c at in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Ca' rni The applica t all f r II requir i cti S. Complete drawing on reverse side. Signed x Title:VP=Clark Well Date: 13 March 1989 FOR DEPARTMENT USE ONLY } Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by �Slf �} . Date Additional Comment:f�Ig7 Ofi5 t ❑ Stk 466-6781 ❑ Ladi -3621 ❑ Manteca 823-7104 D Tracy 83 -6385 : Applicant Return all cop/les to: Environmenta Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 p-" �y J� ��ccs lei/! u..e,14jcl 0 M e its' ��]L t . •4� FEE AMOUNTDUE AMOUNT REMITTECK INFO ASH RECEIVED BY DATE PERMIT'NO. 32L +"EH 1241REV.airs! 2� g� ��I 1 .. EH 144--28