87-815 - Laserfiche WebLink

Home Browse Search

TV APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete inTriplicate) 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. a _ Job Address 1720 E. ,WTLLOWr .: City STOCKTON Lot Size Y PM $ Owner's Name AMERICO CHALIS Address Phone 465-8818 ContractorVETTRR PLEGl. CO -- Address License No. 202228 Phone 463-1706 TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANC EAREST. SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �— DATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED,USE NA TYPLE OF WEL OBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial EJ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 11 Tracy Type o _ Specifica_tions ❑ Public ❑ Other _ ❑ Delta x Depth of Grout Seal Type of Grout ❑ Irrigation �4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') DepthFiller Material (Below 501 `. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO { o septic system permitted if public sewer is I I� i vailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other-- — Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet: f Water table depth k SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ve 1 Method of Disposal Distance to nearest: Well,' Foundation _ 'Pr'operty Line I ��. S✓ � � '' I if' LEACHING LINE El NO. & Length of lines Total length/size k I FILTER BED ❑ Distance to nearest: Well Foundation Property Line { SEEPAGE PITS ❑ Depth Size" 1:: Number t t t SUMPS Ll Distance to nearest: Well 4 4-Foundation6 Property Line.....C� � DISPOSAL PONDS ❑ I�: ,- l 'P' 4"" 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: "t certify that in the performance of the work for which-this�permit.is issued, I shall not 1 employ any person in such manner as to become subject to workman's compensation law§of California." Contractors hiring or sub-contractirid 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 applican ust call r all re�`luir inspections. Complete drawing on reverse side. / ' I Signed x �� "�— Title: PRESIDENT -'' Date: 3/20/87 F EPA MENT USE ONLY Application Accepted by k Date ` Area D Pit or Grout Inspection by Date Final Inspection hu Date 3 Additional Comments: ❑ Stk 466-6781 ❑ Vodi 11369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to:;Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I INFO FEE AMOUNIT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIVNO. + EMI 3-24iREV.t/asi (,M✓ 35•vv �j eQ'� 3--I� �(�� EH 14-26 ✓Jf �C!O l]