88-329 - Laserfiche WebLink

Home Browse Search

- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �,ME 1601 E. HAZELTON ON AVE., STOCKTON, CA REG114 E Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED `fig X119 (Complete in Triplicate) rHFEp`��N Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the woc}c (i�b�cC �E*i q` Splication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rul nd f�wi s of the San Joaquin Local Health District. Job Address �� / /� �r/�/��; t Gityl.4/.E'r�� ! CctLot Size/'V� !PM XOwner's Name/ �� ' �I Jr Address , Q�u�f(<fl�G av�a4- Phone e� � Contractor w �L ) t1/�AaJ!IS License No./ PhJn h TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER L14ES DISPOSAL FLD 7 A -PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1p M Public ❑ Other fl Delta Depth of Grout Seal Type of Grout i I Irrigation —Approx. Depth l I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIWADDITION [ I DESTRUCTION { I (No septic system permitted if public sewer is (� available within 200 feet.) Installation will serve: Residence v`/Commercial_ Other Number of living units: --/- Number of bedro ms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK &;r' Type/Mfg Capacity--Z�4J J No. Compartments PKG. TREATMENT PLT. ❑ ` Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L'I No. & Length of lines Total length/size .z FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ - SEEPAGE PITS /I Depth 2.3 - -Size - Number—2 SUMPS ❑ 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 District. 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 parsons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed XTitle: Gir.J Date:;52 Z9 J-- ,P FOR DEPARTMENT USE ONLY ] ,f _ �] Application Accepted by tiLC �-�`�-� Date /y, Arga / PAYMENT Pit or Grout Inspection by Date Final Inspection by Additional Comments: Im �`/ 7 Jff ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 FE B -5 1988 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 ENVIRONMENTAL HEALTH IFEE NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE ICES + EH 13-21(REV,1/H 51 �6✓ , 4r%/ EH 14-28