COMPLIANCE INFO_1978-1992 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 RECEIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) MAY 0 9 1989 �application Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install �is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and t I San Joaquin Local Health District. ENVIRONMENTAL EALTH DION Job Address �/��/t/r ll ®4M1j�A. /4-L •4NT0Y &Xk City STOGKTanI Lot Size Owner's Name C/Ty ®F L5WC TKZ / Address v/TSS &4!L 4!L Phone PM Contractor S�PEGTR U w1 Cjt D A. Address 2845 li+95 i /° rV R 7 -tit _sT License No. J/ Z Z 6 Phone ZO ' y6r It7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 21S'v,�o 3cZPNr.S (- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LYNNE�To��N6 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE ❑ Industrial [,_,Domestic/ Private ('1 Public I I Irrigation Repair Work Done ❑ Well Destruction ❑ TYPE OF WELL ❑ Open Bottom 19'G -ravel Pack n Other 15..Approx. Depth Type of Pump Well Diameter _ Depth PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Manteca Dia. of Well Excavation 4r f L Dia. of Well Casing ❑ Tracy Type of Casing SCh 10 IP ✓t✓ Specifications F-Ttelta Depth of Grout Seal 30 Type of Grout ef-►0`1f rr I I Eastern Surface Seal Installed by S,PCG7R(1AA Ex,?t _ H. P. State Work Done Sealing Material (top 501 Filler Material (Below 501 WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Other Water table depth _ Capacity No. Compartments Distance to nearest: Well Foundation LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Well Foundation Method of Disposal Property Line Total length/size_ Property Line SEEPAGE PITS I 1 Depth Size — Number SUMPS Ll 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 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: "1 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 applicatV must gall for all required inspe ' ns Complete drawing on reverse side. % Z.( Signed Title: ` &A&m Date: �j. FOR DEPARTMENT USE ONLY Application Accepted by - 1 / n. �-J�� Date � AreaOf c Pit or Grout Inspection by Date Final Inspection by __G ! / Date / O Additional Comments: ^J s a t 0 L >�- liM e// Q_�% o .- g4 .a- z ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca d3-7104 ❑ Tracy 835-6385 Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 e EH 13.241REV. 1/xs EH 14-2a FEE INFO AMOUNT DUE AMOUNT REMITTED K -H RECEIVED 8Y DATE PERMIT NO. OU do irs- ha3y