90-567 - Laserfiche WebLink

Home Browse Search

F Y ` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T Ofd AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 �ci� vE® PERMIT EXPIRES TYEAR FROM DATE ISSU (Complete in Triplicate) IAR 0 7 1990 f Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or iri"N)JQAQLA e1 This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pumIPa�UG I b �;�t71`01 f the San Joaquin Local Health District. ,,, �. . , ENVIRONMENTALH€A�.rFf ijiV1S10N Job Address E Contex March I.te and West Lane City Stockton Lot Size PM Owner's Name _tel Corporation Address 2175 North Califomia Blvd. Phone 415-945-7676 Contractor S=trtm Drilling �_Address 2825 East MYrtle St. License No, 467252 Phone 209--465-8712 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑""' SYSTEM REPAIR ❑ OTHER X Soil Borings/no well instal DISTANCE TO NEAREST:_SEPTIC TANK nOM SEWER LINES none DISPOSAL FLD. POM PROP. LINE (gas) 150ft FOUNDATION none AGRICULTURE WELL POM OTHER WELL 150 ft PITS/SUMPS _ i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial - ❑ Open Bottom ❑ Manteca Dia. of tAlel4 Excavation Dia. of Well Casing NA ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of�Qjjg NA Specifications ' (-I Public ❑ Other fl Delta Depth of Grout Seal 50 ft M Type of Groutbentonite I I irrigation --Approx. Depth LI Eastern Surface Seal Installed by 5P9_C m Drilling Repair Work Done ❑ Type of Pump`, H.P. State Work Done l Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth _ Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION l I DESTRUCTION E I (No septic system permitted if public sewer is available within 200 feet.) V 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line IN LEACHING LINE ❑ No. & Lr=ngth of lines Total length/size I FILTER BED © Distance to nearest: Well Foundation Property Line I SEEPAGE PITS # I Depth I Size Number I 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 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."Contractors 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." I The applicant mu for all eq ed inspections. Complete drawing on reverse side. Signed X _ � _ Title: 12ro1eCt Geologist Date: 2128190 r- R PA NT USE ONLY Application Accepted by ,... Date Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 '❑ Manteca 823-7104 ❑ Tracy •835-63385 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 CASH RECEIVED BY DATE PERMIT'No. +.EH 13-24(REV.r/H 5) 3 S �� - :3 -lei-yU EH 14-29 I. -