85-1112 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN f OCAL"HiAL7H DISTRICT 1601 E. HAZEL"TON AVE, s r , STOCKTON, CA Telephone (209) 466.6781 1 PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED ' Application is hereby made to he San Joaquin Local Health District for(Complete pe permit `� + �IDOI,Ir: '� �� , Wit... , i } c { made in compliance with San Joaquin County t Local Health District, C' v� ty Ordinance No.549 for sewage or No. 9862 far well/ and the Ryles and Regulations,of Ns San Jaa uin o construct and/or in the work herein described, This application is Job Address •,. w q x ` City Lot Size Owner's NameeAD �'; lcC AM Address LV _ Contract `Phone—/A Address / "° / � '•`a TYPE OF WELL/PUMP: t0 j,i NEW WELL ❑ License N Phone , t ' 7j`- PUfyIP NSTALiATIOIV Q WELL AEPLACEMEN f❑ ` DISTANCE TO NEAREST: SEPTIC TANK DESTRIJETION ❑ `�`+ .�. �--�--^-�.=�-,,:�. ,•,;Sy.S7E'M REPAIR ❑ SEWER LINES, , �"-- - OTHER ❑ FOUNDATION DISPOSAL FLED.• ' INTENDED USE • -~ AGRICULTURE WELL -�. PROP. LINE TYPE OF WELL t/ OTHER WELL pITS/SUMPS ❑ Industrial "`*'ROBLEM A CONSTRUCTION SPECIFICATIONS ❑ Open BOttom p Manteca r ❑ Domestic/Private Dii. of Well Excavation �' ' ❑ Gravel Pack, -- 0-Tracy—,1 ❑ Public ! Type of Casing Dia. of Well Casing l] Other EJ Irrigation !.- - �f Specifications ❑ Delta Depth-of Grout See! Repair Work Done ❑ ___AP ptox. Depth ❑ Eastern �# ,J. �_. Type of Grout Type of Purr1p ,I'Sfurfac Sea al Installed by c= E Well Destruction " H,P. J 3 s ❑ Well Diameter _1 State Work.Done f Depth -� Sealing Material (top 50') . TYPE OF SEPTIC WORK: ler Mate ial {g'elow NEW INSTALLATION ❑ REPAIR ADDITION r ' DESTRUCTION ❑ p system t Installation will serve: Residence tNo se tic s tem Permitted if public sewer is Number of-living units: -' --- Commercial j� Other ` available within 200 feet.) - Character of soil to a depth 3 feemSt: _= SEPTIC TANK PKG. TREATMENT ALT. F1Type/Mfg Water table depth m Capacity No. Compartments 1�v Distance-to-nearest:-�- Well- - _ Method of t w Foundati&-n""-`„"----- Disposal #CINEr, ,: ' ; # �� Propetty Line LEACHING _7 r ' "b"1Vii& Lengtfi of'fi es � '. s FILTER BED ❑� Distance to nearest: Well Tota! length/size Foundation�� Pro e SEEPAGE PfTS P rty.Line I -? SUMPS Depth Size «. _ ElDistance to nearest: Well ��-t t a Number DISPOSAL PONDS ❑ "�-"— Foundation�{ pro e I hereby certify that I have prepared this application and that the work will be done in p rtY Line rules and regulations of the San Joaquin Local Health District. accordance with San Joaquin county'ordinances, state laws, and Home owner or licensed agent's signature certifies the following; "I certify that in the employ any person in such manner as to become subject to workman's compensation taws of California."Contractor's Kirin certifies the following Performance of the work for which this permit is issued, i shalt not tion laws of ollowi nra. I certify that in the performance of the work for which this permit is issued, I shall em !o employ persons su`bjeot to wob-Corkman's compensae The applican must call for req iced inspections. Complete drawing on reverse side, ' � Signed Title: - �Af�_ FOR D PgpTMENT USE ONLY ; Date: r Application 13 Accepted byy it r Grout !ns Date d` Inspection by v Area Skt '��O Date 6f-rl Final Inspection by Additional Comments: _ Date eC_'i: ❑ Lodi. 369-3621 ❑ Manteca 823 7T04�`- Applicant- Return all copies to: Environmental Health Permit Trac ; /Seivices 1609 Eo on A_6385 Box 2009 T } r _FEES _ f _ 5ik.. CA 95209 INFO ;AMOUNT DU AMOUNT REMITTED CK# r EH 13-24(REV-ties) CASH RECEIVED BY . DATE — -___— EH W26 t PERMIT NO, i