88-1993 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN,LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES i-YEAR FROM DATE ISSUED E (Complete in Triplicate) f 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. g A t Job Address © "� t� V to L1 City V Lot Size pM Owner's Name L r 1 Y'b! Address Phone Contractor I dress ` �lC.L 0 License No. Q $ Phone �t,j- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE ITYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial - ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I1 Public n Other CI Delta. Depth of Grout Seal Type of Grout O I I Ifrigation —..Approx. Depth I l Eastern Surface Seal Installed_by Repair Work Done ❑ Type of Pump H.P. _ ' + State Work poria_ Well Destruction ❑ Well Diameter Sealing Material (top 50'); Depth Filler Material (Below 50%, TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION TRUCTlON septic system permitted if public sewer is available within 200 feet.) t Installation will serve: Residence %_Commercial Other 1 Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg i Capacity i No+Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: jWell Foundation Property Line LEACHING LINE ❑ No. & Length of lines ! Total length/size FILTER BED ❑ Distance to nearest: I Well Foundation Property Line SEEPAGE PITS I I Depth F Size Number SUMPS Ll Distance to nearest: Well FoundationProperty Line DISPOSAL PONOS ❑ t I hereby certify that I have'prepared this application and that-the work will"be done irl accordance wifF�San Joaquin county ordinances, state laws, and rules and regulations of the San]Joaquin Local Health District. t 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 a y person in such manner as io become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies th Ilawing: "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 lifornia." ` t f # The applican m st all a,all r vire s o Co ate drawing on verse si g Signed r Title: bate: i4t e- FOR DEPARTMENT USE ONLY Application Accepted by Date _ Area—_ Pit or Grout Inspection by Ti Datall �� G Final Inspection by �if` K�'r–'ISL pate�+3 a Additional Comments: 7 ❑ Stk 466-6781 ❑ L r 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 W. Applicant -Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK CASH INFO RECEIVED BY s DATE PERMIT'NO. I a.EH 13-24 IREV-i i N 91 ��}�` �✓ �� r EH 14-28 v