90-1045 - Laserfiche WebLink

Home Browse Search

t ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 1 5 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED, 1 " (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 18846 N Hwy 99 City T,od i Lot Size. 2 n p1PM l _' 1 Owner's Name ViCtor Fine Foods Address ___Same Phone aha 393 f ` Contractor Clark Well Address 2024'F. (' art ar License No. 3 7 15r�Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTIOX)t:3C PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing Specifications I F] Public 171 Other ❑ Delta Depth of Grout Seal Type of Grout :J a T I I Irrigation _.Approx• Depth t I Eastern Surface Seal Installed by _ Q Repair Work Dane ❑ Type of Pump H.P. State Work Done _ 1 Well Destruction �r-'>Weil Diameter 1 6 rt Sealing Material (top 50') 0 Sack sand U11--iLlellIt Depth __3-4 Filler Material (Below 501 same ` TYPE OF SEPTIC WORK: NEW INSTALLATION t l REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) l Installation will serve: Residence_ Commercial Other I Number of living units: Number of bedrooms f 2 Character of soil to a depth of 3 feet: Water table depth p SEPTIC TANK ❑ r� Type/Mfg Capacity No. Compartments LU PKG. TREATMENT PLT. ❑ Method of Disposal ( 4 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line k SEEPAGE PITS I 1 Depth Size Number SUMPS L-1 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, anl� (V� rules and regulations of the San Joaquin Local Health DFstrict. �r Home owner or licensed agent's signature certifies the following: fy pe ) g g g: "i cer[i that in the performance of the work for which this permit is issued, k shall not j 2 employ any person-in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature i certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of C ifo i . 1. The applica II o all r ire s ctions. Complete drawing on reverse side. Signed X Title: Date: 3—E+9ar FO EPARTMENT USE ONLY Application Accepted by Date 1 V Areaq ( Pit or Grout Inspection by Date Final Ins ection by W ec.c�d Date -`��- n� Additional Comments: Q r l Y LIStk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 Tracy 5 Applicant- Return all copies to: r ental He th Permit/ rvices 1 1 E. Iton Ave, P.O. Box 2009 Stk., 95.201 4 INFO FEE A OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO h r.EH 13-24 IRCv.1/K5) CL EH 14-2e 1. .