87-1486 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT, A. i SAN .lOAOUIN LOCALkI�EALTH DI SAN 1601 E. HAZELTON AVE.�,'STOCKTON, Cpl, Telephone (209) 466-6781 ,:an :n ' PERMIT EXPIRES 1 YEAR FROM DATE IS tt>t) J `L u.— (Complete in Triplicate) application is ' Joaquin Local Health District for a permit to construct and/or install the work herein descnbed This app + Application is hereby made to the San 4Wellµ i F h�I ; ax ri a uin,County Ordinance No.548 for sewage yr No. 1862 for /pud th Rebs and Relgulatior►s of tfis San Joaquin k made in compliance with San Jog Local Health District. + ' s A'" } rE PM 11 e City gti � s�a s akz� Job Address ! Phon l c7 6/ Address ¢ Owner's Name Phonie"; � IIIVVV License No. PEST UCTION_❑ *"t' :4 Contractor's Name NEW WELL ❑ WELL REPLACEM, ENT ❑ CIT y- s TYPE OF WELLIPUMP:.' SYSTEM REPAIR l ` ' a > ❑ [ NE PUMP INSTALLATION ❑ PROA LI SEWER LINES- AL i W M-- - DISPOS �• , ` DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL--�-�--•-� PITSISU P>; :� FOUNDATION — I E OF WELL PROBLEM EA CONS TYPE TRUCTVON SPECIFICATION S- pro 'of VV e�i Casing "1 INTENDED USE ❑ Manteca Dia. of Well"Excavation Sc[gtlonS . 4 C] open Bottom ` ❑ Industrial p Tracy Type of Casing Type nf7prout Domestic/Private ❑ Gravel Pack Depth of Grout Seal �• p Other ❑ Delta ❑ Public Su ce Sea1 Installed by . ❑ irrigation _Approx. Depth Q Eastern State Work Ione H.P. I Repair Work Done Type of Pump H.P. Material {top 50'1 Sealing r Well Destruction ❑� tWell Diameter -- Filler Material IBelow"50'} ublic sewer is ` z , f)e -- rmitfed'd P ! REPAIR/ADDITION ❑ ..DESTRUCTION ❑ alvaiiablewthne200 feet�l I TYPE OF SEPTIC WORK:-'NEW,IIVSTAtIATION Q Commercial Other Installation will serve: Residence �— i Number of bedrooms�� Wateraable depth Number of living units: _ c Ca; �� No Compartments Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg 'x Method of pisposyal a h PKG. TREATMENT PL7. ❑ -,Property Line Distance to nearest: Well Foundation Totallengthls[ze LEACHING LINE s' ❑ No. & Length of lines Foundation�� Firpperty On$----c—; FILTER BED Distance to near. Well ' � v r Number` [n `< Size Line e = SEEPAGE PITS Foundation 1 Property I ❑ Dep -- SUMPS ❑ Distance to nearest: Well Q mances, state laws. and DISPOSAL PONDS `- lication and that the work will be done in accordance with San Jgaqu[n county-'tt l hereby certify that i have prepared this app rmrt is[sued, I shalt not rules and regulations of the San Joaquin Local Health District. I certify that in the performance of the work f-r wh[ch ,_; pera Home owner or licensed agent's signature certifies the following' " nsation laws of Cal-[forma." Contract Qsns�subiect t workman's compensa- employ any person in such manner as to become subject t workman's comps 1- lcertify that in the performance of the work for which this permit Is issued i shah employ pe certifies the following:" tion laws of California." 6 `�-.0 n ' f The applicat call far all requir nspec ns. Co ete drawing on reverse side. t Date` Title: Signed FOR DEPARTMENT USE ONLY ` Date Application Accepted by s Date [ Date Final Inspection by t . Pit or Grout Inspection by Additional Comments: Q Tracy 835-6885 C] Stk 466-6781 119-3621 ❑ Manteca B23 7104 ❑ Lodi 3 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E- Hazelton Ave 0.0- Box ,Ftk, CA 951 CDATE. PEHMIT'NO. K RECEIVED BY FEE AMOUNT DUE .AMOUNT REMITTED CASH J INFO ! - F." - + EH 1326[REV.101831 EH 1426 - _