88-2699 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA O Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED OCT G 1988 (Complete in Triplicate) ENVIRONfvS��dTIAL I-IL'ALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work her9iRbAk&5fiR`afQl4plication is made incompliance 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. Job Address City Lot Size �j CPM Owner's Name .� . Address Phone T J A` �,s Contractor ddress ense No.' T i Phone 'a& o TYPE 0 WEL /PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Tl�, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST;,SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial -- ❑ Open Bottom: ❑ Manteca Dia. of Well Excavation Dia. of Well Casing. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications I'1 Public Cl Other Cl Delta Depth of Grout Seal Type of'Grout Depth-. -t I Eastern Surface Seal Installed.hy Repair Work'Done O Type of PumpiH.P. State:Work Done Well Destruction 1NeIl Diameter •ls� Sealing Material (top 501) Depth Fillec..Material(Below 501 S TYPE OF SEPTIC WORK: :NEW INSTALLATION I I REPAIR/AD©ITION I 1 DESTRUCTION I 1 (No septic system permitted if public sewer is _. available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units- Number of bedrooms Character of soil to a depth of!3 feet: Watertable depth r SEPTIC TANK ❑, Type/Mfg Capacity No' Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to dearest: Well Foundation Property Line LEACHING LINE 0No. & Length of lines Total length/size FILTER BEYD' --E1: to nearest: Well Foundation Property tine _ SEEPAGE PITS 11" Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property tine 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 orsub-contracting-signature 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.' The applicant must call for e4 ire inspections. Complete drawing o everse side. Signed X Title: Date: .0/� FOR DEPAPtTME USE ONLY Application Accepted by r Date ` / Area v Pit or Grout InsPection;byInspection-._e.._ Final by µ..... Date Additional j } Additional Comments: O-todi.-369-3621 0 Manteca 823.7104 (3 Tracy_835-6385 Applicaht - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,P.O. Box 2009, Stk., CA 95201 r ; __..- INFO- ._-.-A UN7 DCJE AMOUNTREMITTEtS' CASH RECEIVED BY. DATE PERMIT NO. . �. A"% EH 1324(REV s> ,1s♦ EH 4-26 - i T 9