90-621 - Laserfiche WebLink

Home Browse Search

s APPLICATION FOR PERMIT CEF?r i SAN JOA�QUIN LOCAL HEALTH DIST RII; r: 1601 E. AZEL T ON AVE., STOCKTON, CA MAR 2 0 19 Telephone ,(209) 466-6781 PERMIT EXPIRES TYEAR FFiOM DATE ISS RONME4 NAL HEALTHI ,(Complete in i � 1T/SERVICES SITriplicate) I Application is hereby made to the San Joaquin Local Health District for a per 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 JaCk Tone Rd. City Lot Size PM Owner's Name JAN WARMERDAM� A� dress 16380 N. JdCk Tone Rd. Phone F 17754 N. Hwy. 88 Contractor-�QP.�11"_LC1C� Pt]fi1� Address License No. 309031; Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ l PUMP INSTALLATION ❑ I SYSTEM REPAIR X5: OTHER ❑ ? DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t - -- - 3- INTENi3ED t�SE--= *P-E=OF-WELL T ' -ROBLEM A43EA�=CONSTRI CTION SP:EGIFICATIONS >» --- -- ---- -�~ 11Industrial ❑ Open Bottom C] Manfe ca Dia. of Well Excavation Dia. of Well Casing ! ❑ Domestic/Private El Gravel Pack EI Tracy Type of Casing Specifications k F1 Public F1 Other c�, -i,_- a-Delta`-;'Depth of-Grout,-S Type of Grout I I Irrigation —.-Approx. Depth I•I EasOW— "`' —Surface-Seal-Installed by- - Repair Work Done k Type of Pump Ttirhi na H.P. 5 '# I State Work Done Well Destruction ❑ Well Diameter Sealing Material ftop 50'I Depth t Filler Material (Below 50') 4 TYPE OF SEPTIC WORK: NEW INSTALLATION {'I REPAIR/ADDITION l I DESTRUCTION [ I (No septic system permitted if public sewer is t T available within 200 feet.) Installation will serve: Residence` Commercial I Other { !Number of living units: Nurmber of bedrooms Character of soil to a depth of 3 feet: �M Water table depth [ SEPTIC TANK ❑ Type/Mfg �M Capacity No. Compartments t k PKG. TREATMENT PLT. ❑ IM q Method of Disposal I Distance to nearest: WellI Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size '!F Number SUMPS 0 Distance to nearest: Well Foundation Property Line Q DISPOSAL PONDS ❑ I 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. - - k Home owner or license ant's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ aApersonmanner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies tertif that in the performance of the work for which this permit•is'issued, i shall employ persons subject to workman's compensa-tion laws The appliI required inspections. Com late drawing on reverse side. Signed X �. Title: Date: 3/16/90 i - ///� I� FOR DEPARTMENT USE ONLY Application Accepted by r ___�__ Data ' Area Pit or Grout Inspection by data Final Inspection by --fes o �/ �-� � Date Additional Comments: I� I ❑ Stk 466-6781 L] Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Pehrmit/Services 1601 E. Hazelton Ave., P.O. Box 20W, Stk., CA 95201 � If FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO F CASH +.EH 13-24(REV.,IR5) l EH 1428 I� i