89-334 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT I` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVI ., STOCKTON, CA i Telephone (209) 466-6781 I PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) application is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/orinstall the work herein described.This app' made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the Sen Joaquin Local Health District. rZ.,1ridEY1 Lot Size PM f 7474 N. Cox Rd - city Job Address �s Name Deana Cane a Address 747 4 N. COX Rd. Phone owner Contracto�'urvi ante Dr ille rs AdCZ44 P. O. BOX 64 L�n�� h,, NotZ . 37_7;9 3 Phone 887-3� 4 • NEW WELL WELL REPLACEMENT 1:1DESTRUCTION 171TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑ PUMP,INSTALLATION ❑ SEWER LINES � DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS j FOUNDATION AGRICULTURE WELL OTHER WELL .• : f INTENDED USE TYPE OF WELL PROBL_ EM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing �2 3 4 Dia- of Well Excavation ❑ Industrial Open Bottom [3 Manteca . 188 j Type of Casing ` 4ate?1 Specifications — ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp Type of Grout S71 Other ❑ Delta Depth of Grout Seal f' [,, .,)�public Surface Seal Installed by < �kArrigation Approx. Depth ( I Eastern State Work Done H.P. Repair Work Done ❑ Type of Pump Sealing Materia! (top 501) Well Destruction ❑ Well Diameter Filler Material (Below 50'i ! Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l 1 DESTRUCTION I I anvailableseptic wi within 200 feetit�ed i( public sewer s l Other !1E Installation will serve: Residence Commercial f y \ Number of living units: Number of bedrooms F I Water table depth Character of soil to a depth of 3 feet: No. Compartments Capacity SEPTIC TANK " Type Mfg ._�.�____ _.- A _ Method of Disposal PKG. TREATMENT PLT. Distance to nearest: Well Foundation Property.Line a M r Total length/size LEACHING LINE ❑ No. & Length of lines Property Line E FILTER BED ❑ Distance to nearest: Well Foundation P Y 4 l l Depth Size Number SEEPAGE PITS F:A Property Line SUMPS Ll Distance to nearest: Well Foundation I DISPOSAL PONDS ❑ f; ` I hereby eertity 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 Diltrict.1 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 parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature l 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." f - Theapplica ust call It 'It ui inspections. Complete drawing on reverse side. 2/8/88 Title: President Date: Signed X - FOR Q,EPARTMENT USE ONLY Date Area Application Accepted by e Final inspection by Data Pit or Grout inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 i CK FEE AMM6( AMOUNT REMITTED CASK RECEIVED BY DATE PERMIT NO, INFO i.EH 13-24 4REV.r/n sl Fer - ✓'' 7 EH 14-2a