88-1957 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT !i �V SAN JOAQUIN LOCAL HEALTH DISTRICT, , ".e� 1601 E. HAZELTON AVE., STOCKTON, CA p ' Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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. t 840 Job Address F�Dod, f 1nG��f 1 City Lot Size PM Owner's Name. L!md V6 Ob ft n4ts' ��W IWAddress reel Phone U U ! )6��.�eAldress P In- "^i` & 4 nd� License No.-V71� Phone r�f7!3�"' I Contractor - _ TYPE OF WELL/PUMP: /` ' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION „ PUMP INSTALLATION ❑ SYSTEM REPAIR'O OTHER ❑� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ^' -FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t 't,.{i INTENDED USE. > TYPE OF.WELL:, PROBLEM AREA l CONSTRUCTION SPECIFICATIONS [IIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing *sa. Vii: /t �� ''I- -t ,. i` ❑ DomesticlPrivate ❑ Gravel-Pack C3 Tracy Type of Casing Specifications FI Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation . --Approx. Depth I 1 Eastern Surface Seal Installed by ,,{{ �� Repair Work Done ❑ Type of Pump H.P. State Work Done&h4r)CIar) W-01.f Well Destruction21"Well Diameter Sealing Material Itop 501 nn �Af'�t� Y pR J2�1 r Depth .y f— Z Filler-Material IBelow 50'1 S 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I -REPAIR/ADDITION i l DESTRUCTION I I Mo septic system permitted if public sewer is available within 200 feet.) , ' 4 Installation will serve: Residence— Commercial Other Number of living units_: Number of bedrooms { i Character of soil to a depth of 3 feet: Water table depth j SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Q PKG. TREATMENT PLT. ❑. Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of'lines — Total length/size FILTER BED ❑- Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 Depth Size _ Number 1 SUMPS El Distance,to'nearest:- Well Foundation Property Line DISPOSAL PONDS ElGf".• 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 certifie§-the following: "I certify that in the performance of the work for which this permit is issued,i shall not t employ any person in such manner as to become subiect to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that.in the performarnce'of the work for which this-permit is issued;I-shall employ persons subject to workman's compensa- tion laws of California." The applic� must cal .9r 11 quir inspections. Complete drawing on reverse side. Signed X le: Date: FOR DEPARTMENT USE ONLY Application Accepted by .Date Area Pit or Grout inspection by Date Final inspection by Dat Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 I FEE INFO AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE PERMIT'NO. _ s � - a EH 13-24(REV.,t i et sl 3 S•, ��[�/ r� - EH 14-28 - E`