87-1184 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCACHEALTH DISTRICT 1601 ic. A HAZEL I ON VE., STOCKTON, CA i Telephone (209) 466-6781 F s i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED'' dq 4 (Complete in Triplicate) s ,.-it , .; THsapplication IS ll the work ocal Application is hereby made to the San Joaquin fd Hance No.D549 far sesiva9r a pe e o(No 1862 fort to construct and/or and the Ryles and hereinR gulations of the San Joaquin ` made in compliance with San Joaquin C€untyC 1. E Local Health Distiict. .rr ''fir-, f1. (" ( PM r, ,t~ ttt Ciry' d� Cot Size Ln 3 �: . 1 14. � . - Job Address rvy� 7 � a, .L Phone Address� 2 Owner's Name phone (\ pN / vim_. License Not !� Address( DESTRUCTION ❑ ContractorWELL REPLACEMENT ❑ NEW WELL ❑ OTHER El TYPE OF WELLIPUMP: SYSTEM REPAIR L� PUMP INSTALLATION ElDISPOSALFLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC j SEWER LINES - 1 PITS/SUMPS i TANK AGRICULTURE WELL OTHER WELL FOUNDATION ? INTENDED T_Y.P.E_OF_W.ELL_: PROBLEM.AR -�CONSTRUCTIONSPECIFICATIONS """'Dia. of Well Casing ❑ Manteca Dia. of Well Excavation ❑ Industrial ❑ Open Bottom Type of Casing Specifications ❑ Gravel Pack ❑ Tracy Type of Grout L�omesticlPrivate ❑ Delta > Depth of Grout Seal ❑ Public ❑ Other rax. Dept ❑ Eastern Su Ge Seal Installed by B n " ❑ Irrigation app la [I State Work Done I Repair Work Done [� Type of P�mp ISealing Material [top 50'1 i Well Destruction ❑ Well Diam&ter —� Filler Material (Below 50'1 t-E Depth available within 200 feet.( TYPE OF SEPTIC WORK: NEW INSTALLATION Q REPAIRIADDITION ❑ pESTRUCTlON ❑ (No septic system permitted if public sewer is 4. { fi Commercial Other�- Installation will serve: Residence"— Number of living units: Nmber of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity—� No. Compartments SEPTIC TANK ❑ Type 7Mf9 Method of Disposal I PKG. TREATMENT PLT. ❑ Foundation—.—� Property Line�— Distance to nearest: Well I ------ Total LEACHING LINE 0 No--&I+-ength-of-lines— n Property Line FILTER BED ❑ Distance to nearest: Well Foundation f t _ Size Number SEEPAGE PITS ❑ Dept Property Line Foundation SUMPS L3Distance to nearest: Well ' DISPOSAL PONDS ❑ L I hereby certify that 1 have prepared this application and that the work well be done in accordance with San Joaquin county ordinances, state laws,and rules and regulations of the San Joaquin Local Health District. become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature 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, ! shall not employ any person in such manner fy that i to e p 1 certifies the following: u certify that s 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 applica us all ford inspectio :complete on reverse side. pate: LTitle: Signed ' ti FOR DEPARTMENT USE ONLY A Date Date '� � Area Application Accepted by DatA/- Final Inspection by Pit or Grout Inspection by Additional Comments: ElTracy 835-6385 C1 Stk 466-6781 ❑ Lodi 369-3621 [1 Environmental 823 7104 l Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant- Return all copies to: i .I CK RECEIVED BY DATE PERMIT`NO." L FEE AMOUNT DUE AMOUNT REMITTED CASH �7 INFO + EH 1324(REV.t/a 5) © EH 14-26