84-1422 (2) - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT �2 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 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. Job Address�L iQNAPZI7 City Lot Size PM Owner's Name DpiV Grn '54F Address 7`N�� Phone Contractor's Name License No. a 76-tS—r—a— Phone �a Al TYPE OF WELL/PUMP: NEW WELL ❑ ' WELL REPLACEMENT ❑ DESTRUCTION ❑ ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t. 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 ❑ Public 1 ❑ Other ❑Delta_-_,,,:7,_..Depth of Grout Seal Type of Grout ❑ Irrigation ) ----Approx. Depth ❑ Eastern Surface Seal Installedbyi Repair Work Done ❑ Type of Pump H. P. " �-State Work Done Well Destruction ❑ Well Diameter Sealing Material (tap 501 i Depth Z Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION fff AEPAIR/ADDITION.❑_-, L.� ad if public sewer is _ _ - � •�-• -- --avbrf uia�wu uw.ctwi-9Ctx-i�°^-'- Installation will serve: Residence Commercial ' 0 er Number of living unitsi Number of bedrooms, r i Character of soil to a depth of 3 feet:�11DaT5��+'C.4 1✓ Water table depth :: s7 SEPTIC TANK ,� Type/Mfg r '•L 0 Capacity ; No. Compartments PKG. TREATMENT PLT . El aMethed_. of„Disposal- --n., Distance to nearest: Well—•t Foundation _ Property Line 61 ,. LEACHING LINE No. & Length of lines FILTER BED ❑ Distance to nearest:, SEEPAGE PITS ❑ Depths SUMPS t)I Distance to nearest: DISPOSAL PONDS �❑ t. Oji'" 'z �' ,✓ }- Total length/size &'v Well Foundation Property Line A2 � r � _ SizeNumber i s. ar Well' y Foundation'_ Property Line I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin connty.grdinances, state laws, and rules and regulations of the San Joaquin Local Health District. N 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 taws of California." Contractor's hiring or sub -contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ personssuilject to workman's compensa- tion laws of California." The applicant must call fo all required inspections. Complete drawing -on reverse side."# Signed X T_ //lCa� _ Title: i 49L_ tl1� Date: FOR DEPARTMENT USE ONLY V, y ` Application Accepted by �f vl % `` Date ` Area ' /f Pit or Grout Inspection by . Date � Fi'nal Inspection by Date 6 Additional Comments: ' ❑ Stk 466-6781 O Lodi 369-3621 El Manteca 823-7104 ❑'Tracy -835-6385 Applicant - Return all copies to: Environmental Health Permit/ Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 13-24 (REV. 10/83 EH 1126 FEE INFO AMOUNT DUE,_ AMOUNT REMITTED CASH 4•''REC EIV.ED-BY._ .DATE._ _. _PERMIT_NO.,,•- 77 ��-