88-13 - Laserfiche WebLink

Home Browse Search

•C APPLICATION FOR PERMIT' d { SAN JOAQUIN LOCAL HEALTH DISTRICT 4Y 1601 E. HAZE I ON AVE., STOCKTON CA ` I: T Telephone (209) 466-6781 a' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _k (Complete in Triplicate) ENVIROIMEttiTAL HLALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work"iMdffcn'iied?�1`iQraF lication 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, 4 Job Address 1-7-57-0-BETHANY RD. city....TRACY Lot Size PM i Owner's Name DON COSF & ASSO(- Address P.O. Box an TRACY Phone 836-0422 Contractor H FNN T NGS RROS_ DR T 1 Ilddress License No.-2-9-0-8-1-3—Phone 5 4 5- 118 5 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C7 DISTANCE TO NEAREST: SEPTIC TANK 5 5 + SEWER LINES 10 0 E + DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C b El Industrial OW ❑ Manteca Dia. of Well Excavation " Dia. of Well Casing C�(Domestic/Private Grave Pack CX Tracy Type of Casing. PVC Specifications pecifications Q Public `d [�1M Other El Delta Depth of Grout Seal Type of Grout BENT 0 N I T ❑ Irrigation 1[3'—Approx. Depth ❑ Eastern Surface Seal Installed by NC. Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') („ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION ❑ (No septic system permitted if public sewer is Q� 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: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth, Size Number 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."Contractors 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 persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete ra�wing on r v rse side. p Signed Tule: Date: -Z%Z1'a FOWDEEPA�r USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781- ❑ Lodi 369-3621 ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"No. � + EH 13-24(REV.t/a 5) �7 v (qur /f /(��/J go Jf 1 EH 14.28 `F�' "OVIJ 7� Vu .66 V 6